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COPYRIGHT DEPOSIT 



Oral Pathology 



and Practice 



*A TEXT-BOOK FOR THE USE OF STUDENTS IN 

DENTAL COLLEGES AND A HAND-BOOK 

FOR DENTAL PRACTITIONERS. 



BY 

W. C" BARRETT, M.D., D.D.S., M.D.S., LL.D., 

Professor of the Principles and Practice of Dentistry and Oral Pathology in the University of 

Buffalo Dental Department ; Professor of Dental Anatomy and Pathology in the Chicago 

College of Dental Surgery; Late Professor of Oral Pathology in the University 

of Buffalo Medical Department ; Consulting Oral Surgeon to the Buffalo 

General Hospital, etc., etc. 



SECOND EDITION, 

Revised, Enlarged, and Illustrated. 



PHILADELPHIA: 

THE S. S. WHITE DENTAL MFG. CO. 

1 901. 



0- 






THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

APR. 24 1901 

COPYRbiHT ENTRY 

CLASS CL XXO. N». 
COPY 8. 



Copyright, 1898 
Copyright, 1901. 



by W. C. Barrett. 
by W. C. Barrett. 






TO 



My beloved Associates in College Work, 



My Boys. 



THE MEMBERS OF THE VARIOUS CLASSES WHO HAVE 

BEEN UNDER MY INSTRUCTION, AND WHOM 

I HAVE SOUGHT TO SERVE, 

THIS WORK 
IS AFFECTIONATELY INSCRIBED. 



PREFACE TO SECOND EDITION. 



The kind reception accorded the first edition of this book by 
the dental profession was a matter of almost as great surprise as 
gratification. The author did not anticipate that within two years 
it would be exhausted, and a second — which is greatly belated — 
demanded, for works of this kind do not appeal to the general 
public and are restricted in their sale. 

At the outset the publishers strongly urged that the text be 
properly illustrated with cuts, but the author had not sufficient faith 
in his venture to increase the necessary cost of the book by the 
addition. The fact that those interested have generally approved 
his efforts leads him to put forth yet greater exertions to make the 
volume more worthy their confidence. 

Accordingly it has been thoroughly revised, not a chapter now 
reading as it did originally, while much new matter has been added 
and many illustrations have been introduced, the principal ones 
being original with this work. The author has endeavored to profit 
by the honest criticisms of the reviewers of the first edition, and 
sincerely hopes that some of its faults have been eliminated. 

He offers this riper fruit in the hope that it will not only be 

more palatable and easy of digestion than that which was plucked 

earlier, but that it will also prove nutritious and professionally 

healthful. He trusts he may not be thought presumptuous when 

he commends it to the student as a text-book, to the teacher as a 

help in his arduous duties, and to the practitioner as a work for 

daily reference. 

W. C. B. 

208 Franklin St., Buffalo, N. Y., 
October, 1900. 



vi PREFACE TO FIRST EDITION. 



PREFACE TO FIRST EDITION. 

This book is not a treatise, and surgical or operative pro- 
cedures form no part of its scheme. In writing it the first object 
has been to condense, not to amplify, that it may be published at as 
low a price as possible. With this end in view, cuts have been 
excluded, desirable as they might in some instances be. The 
work has thus been kept within the limits of a manual. 

It has been the aim of the author to consider as succinctly as 
is consistent with clearness the functional derangements of all the 
oral tissues that properly fall within the compass of a broad dental 
practice. In addition to this there are certain constitutional dis- 
orders, the effects of which may be observed in and about the oral 
cavity, which have not as yet been incorporated into our specialty, 
and perhaps never will be, but of which it is essential that the 
dentist should have sufficient knowledge to enable him to make a 
clear diagnosis, even if he should not purpose active remedial 
measures. Such disorders as facial paralysis, syphilis, and tumors 
have therefore been given a general consideration, but practitioners 
who wish to make a more exhaustive study of those subjects are 
referred to special works upon them. 

It should not be expected that a writer will blindly and 
unreservedly follow even accepted practice when in his opinion it 
is founded in error; such a course would make of him a mere echo, 
and would inhibit originality and progress. If, therefore, the 
author has advanced his own ideas upon subjects concerning which 
there is a difference of opinion, he believes them entitled to candid 
consideration in the light in which they are presented. If not 
found in harmony with clinical experience and observation, they 
disprove themselves. 

It is only within a few years that Pathology as a separate study 
has been made a distinct part of the curriculum of our colleges. 
The treatment of a few of the more pronounced pathological condi- 
tions has always been included in the course of lectures upon 
Operative Dentistry, or in that of Materia Medica and Therapeu- 
tics, but the subject has been made rather incidental than founda- 
tional. With the growth of dental practice and the expansion of 



PREFACE TO FIRST EDITION. Vll 

the course of instruction in our colleges, a more extended con- 
sideration of the treatment of complications naturally attendant 
upon dental degenerations becomes a necessity in our best schools. 
Dentists are reasonably plentiful, and the multiplication of institu- 
tions devoted to their iraining is believed to promise an even 
more abundant supply. The complaint that the profession is 
getting uncomfortably crowded arises from the old graduates, as 
well as from those who have been deprived of the advantages of 
scholastic training. 

The remedy for these conditions can only be found in the 
deepening of the stream — in the enlarging of the field of practice 
by incorporating with the methods of the past (the mechanical 
and operative procedures which have already been carried to such 
a high state of perfection) the treatment of the diseases that prop- 
erly fall within the province of the oral physician, and the making 
of Oral Practice a true specialty of medicine. 

For some years the author has annually delivered before his 
classes in dental colleges from fifty to sixty lectures upon patho- 
logical and morbid functional and structural conditions in the oral 
cavity and the tissues immediately connected with it, in which there 
has been attempted nothing of instruction in constructive, opera- 
tive, or manipulative dental work. This has tended to open for 
students a field insufficiently cultivated by dentists. It has en- 
larged their opportunities, added to their emoluments, and given to 
them a better professional status. 

But in this line of teaching he has been seriously handicapped 
by the absence of proper text-books. Excellent treatises were in 
existence, but none of them was exclusively devoted to the every- 
day work of either student or practitioner. They included other 
branches of dental science, and while, as works of reference and as 
text-books for advanced members of the profession who desired 
to make special studies in scientific fields, they were much better 
adapted than a work of this kind can possibly be, yet as hand- 
books for students in colleges and as everyday manuals for those 
who sought help in the hourly recurring complications of office 
life they were too voluminous. 

In the time of Hippocrates it was possible to comprise in one 
volume all that was known of medicine. Many of our older 
practitioners can call to mind the days when the whole art of den- 



Viii PREFACE TO FIRST EDITION. 

tistry was imparted by a preceptor in a few easy lessons. One 
man might then be universally recognized as the highest authority 
in the whole field. Now, a complete knowledge of any one of the 
distinct branches of medicine demands a post-graduate course after 
four years of general study, while three years in a dental college 
are scarce sufficient to enable the student to master the basal 
principles of our greatly extended oral practice. Not alone medi- 
cine, but dentistry is divided into specialties, and already there are 
among us those who give their exclusive attention to Operative or 
to Prosthetic work, to Oral Surgery, to Odontothorsis or to 
Odontotherapy. The tendency seems to be toward the teaching 
of each branch in separate classes, with distinct text-books for the 
several departments. The present work grew out of that seeming 
drift, and the germ of its existence lay in the notes of lectures upon 
the subjects considered. 

The book could easily have been expanded into greater dimen- 
sions, but that would have limited its usefulness among those for 
whom it was specially prepared. Extended abstracts of the writ- 
ings of others might have been included with profit, but that would 
have swollen the volume beyond the limits set for it, and have 
added to its cost. Besides, a book should have a distinctive indi- 
viduality, a personality as pronounced as that of the successful 
teacher, and without this it is usually as insipid as is the man or 
woman who possesses no distinguishing peculiarities. So it is 
perhaps better that it should be marred by some of the many faults 
of its author rather than be without any special traits at all. 

W. C. B. 



CONTENTS. 



CHAPTER I. page 

General Considerations i 

CHAPTER II. 
Bacteriology : Classification 3 

CHAPTER III. 
Fermentation 9 

CHAPTER IV. 
Bacteriological Pathology 14 

CHAPTER V. 
Septic and Aseptic Conditions 18 

CHAPTER VI. 
Inflammation : Its General Characteristics 25 

CHAPTER VII. 
Changes Attending the Inflammatory Condition 32 

CHAPTER VIII. 
Further Degenerative Changes 37 

CHAPTER IX. 
The Products of Inflammation 40 

CHAPTER X. 
General Treatment of Inflammation 47 

CHAPTER XI. 
Diseases of the Gums 50 

CHAPTER XII. 
Stomatitis 54 

CHAPTER XIII. 
Treatment of Stomatitis 57 

CHAPTER XIV. 
Pharyngitis and Tonsillitis 61 

CHAPTER XV. 
Diseases of the Tongue 64 

CHAPTER XVI. 

Dentition : General Considerations 67 

ix 



X CONTENTS. 

CHAPTER XVII. 
The Diseases of Dentition 71 

CHAPTER XVIII. 

The So-Called Diseases of Dentition 74 

CHAPTER XIX. 
Treatment of the So-Called Ejisfases of Dentition 81 

CHAPTER XX. 
The Real Diseases of Dentition 84 

• CHAPTER XXI. 
Dental Caries 87 

CHAPTER XXII. 
The Pathology of Dental Caries 94 

CHAPTER XXIII. 
The Medicinal Treatment of Dental Caries 99 

CHAPTER XXIV. 
Pulpitis — Inflammation of the Dental Pulp. 102 

CHAPTER XXV. 
Treatment of Inflammatory- Conditions of the Dental Pulp 107 

CHAPTER XXVI. 
Pericementitis — Inflammation of the Peridental Membrane in 

CHAPTER XXVII. 
Alveolar Abscess 117 

CHAPTER XXVIII. 
Symptomatology and Treatment of Alveolar Abscess 128 

CHAPTER XXIX. 
Deposits upon the Teeth -. 135 

CHAPTER XXX. 
Pyorrhea Alveolaris 141 

CHAPTER XXXI. 
Pyorrhea Alveolaris (Continued) 144 

CHAPTER XXXII. 
Facial Neuralgias 150 

CHAPTER XXXIII. 
Facial Paralysis 154 

CHAPTER XXXIV. 
Sympathetic Disturbances 158 



CONTENTS. Xt 

CHAPTER XXXV. PAG& 

Diseases of the Maxillary Sinus 161 

CHAPTER XXXVI. 
Treatment of Diseases of the Maxillary Sinus. 167 

CHAPTER XXXVII. 
Diseases of the Frontal Sinus 172 

CHAPTER XXXVIII. 
Cysts and Their Treatment 175 

CHAPTER XXXIX. 
Tumors and Neoplasms 182 

CHAPTER XL. 
Tumors and Neoplasms (Continued) 185 

CHAPTER XLI. 
Osteitis 190 

CHAPTER XLII. 
Caries of Alveolar Bone 194 

CHAPTER XLIII. 
Necrosis 198 

CHAPTER XLIV. 
Treatment Of Necrosis 202 

CHAPTER XLV. 
Hypersensitive Dentine 205 

CHAPTER XLVI. 
Treatment of Hypersensitive Dentine .• 210 

CHAPTER XL VII. 
Secondary Dentine, Pulp Nodules, and Calcifications 216 

CHAPTER XLVIII. 

HYPERCEMENTOSIS 222 

CHAPTER XLIX. 
Discolored Teeth 225 

CHAPTER L. 
Congenital Imperfections of Enamel 227 

CHAPTER LI. 
Acquired or Accidental Imperfections of Enamel 233 

CHAPTER LII. 
Replantation ; Transplantation ; Implantation 238 



Xll CONTENTS. 

CHAPTER LIII. PAGK 

Syphilis : General Considerations 246 

CHAPTER LIV. 
Syphilis : The Primary Stage 250 

CHAPTER LV. 
The Secondary Stage of Syphilis 255 

CHAPTER LVI. 
Tertiary and Hereditary Syphilis 259 

CHAPTER LVII. 
Syphilis of the Mouth and Tongue : Recapitulation 265 

CHAPTER LVIII. 
Physical Diagnosis 268 

CHAPTER LIX. 
Physical Diagnosis (Continued) : The Respiration 273 

CHAPTER LX. 
The Oral Tissues in Diagnosis 279 

CHAPTER LXI. 
Wounds and Injuries 282 

CHAPTER LXIL 
Treatment of Wounds 285 

CHAPTER LXIII. 
Excessive Bleeding 290 

CHAPTER LXIV. 
Fractures and Their Treatment 293 

CHAPTER LXV. 
Special Cases of Fracture 299 

CHAPTER LXVI. 
Dislocations and Sprains 303 

CHAPTER LXVII. 
Shock — Collapse 307 

CHAPTER LXVIII. 
Treatment of Shock 310 



ORAL PATHOLOGY AND PRACTICE. 



CHAPTER I. 

GENERAL CONSIDERATIONS. 

The study of disturbed, as well as of normal systemic condi- 
tions, necessarily commences with the consideration of Function. 

Health and sickness (ease and dis-t3.se) are dependent upon the ac- 
tivities of the organs of the body. In the former condition all are 
harmoniously working together, each accomplishing its proper 
task in the best manner and at the right moment. In the latter 
there is a disturbance of the interdependent bodily relations through 
the inaction or the mal-action of some organ or set of organs, in- 
duced by malnutrition, by unsanitary conditions, or by external in- 
terference. 

Function is the action of an organ, or of a complete set of 
organs. The function of digestion implies the proper action of all 
the organs of the digestive tract, and the perfect accomplishment of 
this requires that each of them shall be in that state of health which 
is secured only by the normal action of all combined. The function 
of every organ is in some way dependent upon that of others, and a 
state of complete bodily health implies perfectly harmonious rela- 
tions in all its different parts. 

The function of insalivation demands that all of the salivary 
glands shall be in a normal condition, secreting healthy saliva, 
and that the saliva shall be properly mixed with ingested food. 
The secretion of the mucous glands is viscid and contains mucin ; 
that of the parotid is largely serous and contains ptyalin, while 
that of the submaxillary and sublingual glands is mixed in char- 
acter. Unless all these secretions are combined the saliva will 
lack some ingredient, and cannot perfectly perform its office. If, 
then, the action of any gland is not normal the saliva is modified, 
and this may interfere with the function of digestion, proper assimi- 



2 ORAL PATHOLOGY AND PRACTICE. 

lation may be inhibited, every tissue of the body may lack nourish- 
ment, and thus from a disturbance in one apparently unimportant 
organ every other in the system may suffer. 

Physiology is the science of normal function. Its proper 
study demands a knowledge of the structure of the organs con- 
cerned. It is not confined to man, or even to animal life. Wher- 
ever there is vitality, growth, organs (that is, in all organic matter) 
there are certain laws that govern the functional activity of the 
organism, and the study of these laws is called Physiology. 

Physiology is divided into animal and vegetable physiology. 
It may again be subdivided until the functional activity of each of 
the various orders of animal and vegetable life is specially con- 
sidered. 

Pathology is the study of perverted, abnormal, or diseased 
function. Its comprehension must be based upon a knowledge of 
healthy action. The study of pathology may be divided in the 
same manner as is physiology. Wherever there is normal func- 
tion there may be diseased or perverted action of the tissues or 
organs, if their activity is in any way disturbed. So we may have 
animal or vegetable pathological action, and we may study this 
aberration in any class of animals or vegetables, even in any 
separate organ or tissue; thus we speak of human or animal 
pathology, and of pathological conditions of the digestive appa- 
ratus, the kidneys, the pulmonary tissues, the oral cavity, the nails, 
the teeth, the hair, etc. This unrestricted nature of the study 
must always be kept in mind, and the fact that in the consideration 
of the diseases that are incident to man we are but making an 
examination of a small portion of the great field of perverted 
activity should never be lost to sight. 

Oral pathology is but a branch of disturbed human function- 
While we may make special inquiries into its character, it can 
never be wholly segregated from its connections, but must 
always be considered in its relations to impaired conditions of 
other organs, because its initial lesion, or point of origin, may 
be in them, and a cure may only be brought about through a 
return of those connected organs to a true state of physiological 
activity. There is no proper study of the oral tissues or organs 
aside from their functional association with other tissues and 



BACTERIOLOGY : CLASSIFICATION. 3 

A physiological state may be changed to a pathological condi- 
tion by any derangement of function. The modifying influences 
which induce this may be classed as follows : 

1. Perverted nutrition (or malnutrition). 

2. Unsanitary surroundings or environments. 

3. External interference. 

Their importance as disturbing factors and the gravity of the 
functional disarrangements induced by them are in the order given. 

Malnutrition means the improper nourishment of the tissues 
or organs. It may primarily depend upon improper food, a lack 
of food, or upon imperfect action of the organs of digestion and 
assimilation. A degenerate condition of these organs is usually 
brought about either by impaired nutrition or unhealthy environ- 
ment, and it may therefore be considered as a secondary cause. 

Unsanitary or unhygienic conditions are those that interfere 
with proper functional activity, by means of some disturbing 
element or influence, such as 

a. Contamination of the air that is breathed, or the food or drink 
that is taken. 

b. Subjection of the organs and tissues to improper extremes of 
temperature. 

c. Promotion of the proliferation and grozvth of parasitic or 
disease-producing organisms. 

External interference has reference to factors not primarily 
connected with functional disturbances. It includes wounds and 
injuries, the influence of excessive heat and cold, the active agency 
of corrosive poisons, and such-like extraneous causes. 



CHAPTER II. 

BACTERIOLOGY: CLASSIFICATION. 

Modern pathological science is largely founded upon a knowl- 
edge and study of the bacteria — a subdivision of the fungi. The 

influence of these organisms upon the body is so overwhelming 
that it is impossible to comprehend pathology without a comprehen- 
sion of their character and action. So manv of the diseases most 



4 ORAL PATHOLOGY AND PRACTICE. 

destructive to man are caused by them, that modern medical science 
is largely based upon their study. Notwithstanding the fact that 
they can only be seen by the aid of the higher powers of the micro- 
scope, and that even then some of them are absolutely indefinable 
to vision, they work the most important changes in matter. Were 
it not for their influence the world would become uninhabitable 
through the using up of organic matter, which would become 
permanently incorporated in unchangeable compounds and the 
pabulum for animals and vegetables thus exhausted. 

The office of the fungi seems chiefly that of destruction. By 
their growth they decompose organic matter in which function 
has ceased, and return its elements to nature, to be again built 
up into other structures by varying functional activities. 

Different names have been given to these organisms by 
different pathologists, though all have the same general signifi- 
cation. 

a. Micro-organism means a small body. 

b. Microbe signifies a small life. 

c. Bacterium (plural Bacteria), a small staff. 

d. Bacillus (plural Bacilli) , a small rod. 

It will be seen that the first two and the last two names are 
practically synonymous. While all these terms may here be used 
interchangeably, micro-organism is perhaps as comprehensive as 
any, although it has no strictly scientific significance. All of these 
bodies that come within the field of the pathologist are microscopic ; 
hence to speak of them as micro-organisms is more appropriate 
than to call them fungi, the latter term including many organisms 
that are merely parasitic upon other vegetable growths, while many 
of the fungi are not microscopic and have no pathological signifi- 
cance. 

In general classification the various divisions and subdivisions 
of matter are usually denominated as follows: Matter is divided 
into Grand Divisions; these into Kingdoms; Kingdoms into Sub- 
Kingdoms; Sub-Kingdoms into Classes; Classes into Orders; Orders 
into Genera, or Families; Genera into Species, and Species into 
Varieties. 

The fungi have been differently classified by various observers, 
each having based his arrangement upon certain special character- 
istics. That of Miller, in his "Micro-organisms of the Human 



BACTERIOLOGY 



CLASSIFICATION. 



Mouth/' is perhaps best adapted to the needs of students of oral 
pathology, and it is therefore accepted as the standard for this work. 
The following table will give a clear idea of it : 

Matter 



Organic 



Inorganic 



Animal 



Vegetable 



Cryptogams Phanerogams 

(Flowerless plants, propagating (Flowering plants, propagating 

by spores) by seeds) 



Thallogens, 
or Thallophytes 



Leafy Cryptogams, 
Terns, Mosses, etc.) 



Lichens 



Fungi 



Algse 



Screw forms Rod forms Round forms 

Vibriones Bacilli Micrococci 

(undulating) (straight rods) (small cocci) 

Spirillae Clostridium Macrococci 

(rigid) (spindles) (large cocci) 

Spirochetas Leptothrix Diplococci 

(flexible) (threads) (double cocci) 

Streptococci 
(chain cocci) 
Staphylococci 
(group cocci) 

Organic matter is that which is the product of function, or 
growth. Everything that has organs, or in which function exists 
or has once existed, is organic. 

The organic world is divided into two great kingdoms, the 
Animal and the Vegetable. Each individual member of these 
great divisions has its organs and its tissues; function exists in 
each as long as there is vitality, or life. Death is merely the cessa- 
tion of function, and the physicist makes no other distinction 
between the dead and the living than the presence or absence of 
functional activity. 

The food of these two kingdoms materially differs. The 
animal can assimilate nothing except organic matter. Thus the 
Graminivora live upon vegetables alone, or matter that has been 
but once organized, and they require a complicated digestive system 
to extract the comparatively small amount of pabulum for their 



6 ORAL PATHOLOGY AND PRACTICE. 

tissues which it contains. The Carnivora feed upon the animal 
kingdom, or matter that has been twice organized; first into the 
vegetable and then into the animal. Their digestive apparatus 
is comparatively simple, because of the concentrated nature of 
their food. The Omnivora, to which division man belongs, can 
subsist upon either, and their digestive organs, while more com- 
plex than those of the Carnivora, are considerably modified from 
those of the Graminivora. 



Fig. i 



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Different Forms of Bacteria. (After Miller.) 

a, Micrococci, b, Diplococci. c, Streptococci, d, Bacilli, e, Vibriones. f, Spirillse. g, Clos- 
tridium, h, Spirochete, i, Leptothrix. 



Only organisms that belong to the vegetable kingdom have 
the power of living upon inorganic, or unorganized, matter. Cer- 
tain of the vegetable fungi are unable even to do this, but must 
have the food organized before they can assimilate it, as must all 
members of the animal kingdom. 

Inorganic matter is that which exists as it was first created. 
This earth, when it left the hands of its Creator, must have consisted 
exclusively of inorganic matter. When, in due process of time, 
the first organic cell was created, and endowed with the power to 



BACTERIOLOGY I CLASSIFICATION. 7 

adapt itself to changing environments and to perpetuate its species 
— in other words, was invested with function — its food, or pabulum, 
must have been derived from the inorganic creation. But only the 
vegetable kingdom has the power to assimilate or organize this 
matter, or to subsist and grow upon that which is as it was 
primarily created. Hence the vegetable was first in the order of 
organic creation, and all organic matter, which is the product 
of function and was primarily derived from the inorganic, must 
have originally been the result of vegetable action. 

No animal can utilize for trophic, or digestive, purposes any 
inorganic matter whatever. This is a law of the creation. All 
the mineral elements that enter into the composition of our teeth, 
bones, etc., must be obtained from organic sources. That is, the 
calcium, phosphorus, iron, etc.,- of our tissues must have been 
derived from matter that had first been built into other life. Inor- 
ganic matter may be utilized in the system as medicine, but it will 
be extruded in the same form in which it entered; it cannot be 
built up into the tissues. Even water, which forms so large a pro- 
portion of all organic bodies and which is itself inorganic, is not, 
strictly speaking, trophic or nutritional, but is interstitial. It holds 
in solution many salts, forms a part of all crystalline structures, and 
is a necessary constituent of the body, though not of the elements 
of the tissues themselves. It necessarily follows, then, that in the 
order of the developmental history of the world, the vegetable 
must first have had a being, to provide food for the animal. 

The vegetable kingdom is divided into the classes Phanerogam 
and Cryptogam. 

The Phanerogams include all those plants which have blossoms 
and which are propagated by seeds. The roots of some phanero- 
gams, as the potato, enlarge into tubers, from which new plants 
may be grown, but their real generation is from seeds. Most of 
the plants with which we are acquainted belong to this class. It is 
the seeds and the tubers of the phanerogams that form the principal 
vegetable food of man. 

The Cryptogams never blossom, and their propagation is by 
spores, or minute embryos of the plant itself. As the potato may 
be propagated from divisions of the root or tuber, so do many of 
the cryptogams grow from divisions of the organisms themselves, 
but primarily their origin is from spore-cases. 



8 ORAL PATHOLOGY AND PRACTICE. 

The Leafy Cryptogams are not microscopic in their character, 
and they have distinct branches and stems. But, like all of their 
class, they grow from spores. The leafy cryptogams include the 
ferns, the mosses, and some of the lichens. 

The Thallogens, or Thallophytes, belong to that division of 
the cryptogams that are unicellular and simple in their structure. 
They are without leaves, stems, or branches. They are divided 
into Fungi, Algae, and Lichens. 

Fungi are without chlorophyll {the green coloring matter of 
plants), and live only upon organic matter. They are found as the 
parasites of both the animal and vegetable kingdoms. 

Algcc contain chlorophyll, but live upon inorganic matter. 
They are usually found growing in the water. 

Lichens partake of the character of both the fungi and the 
algcc. They may or may not contain chlorophyll, and they may 
live upon either organic or inorganic matter, according to their 
species. They are usually found attached to some inorganic matter, 
and obtain their subsistence from the air. 

It will be observed that only the fungi can be of interest to 
the pathologist, for the algae do not grow upon organic matter, 
and hence will not be found parasitic in man, whose structure is 
organic, while the lichens have no pathological significance. 

The Fungi are divided according to their shape, into round, rod, 
and screw forms. 

The round, or coccus forms, are subdivided into the macro- 
cocci, or large cocci, the micrococci, or small cocci, and the diplo- 
cocci, or double cocci, the streptococci, or chain cocci, and the 
staphylococci, or those which grozv in clusters, like a bunch of 
grapes. 

The rod forms arc divided into the bacilli, or straight rods; 
the Clostridium, or spindle-shaped, and the leptothrix, or thread- 
like forms. 

The screzv forms arc divided into the vibriones, or undulating 
screzvs; the spirillar, or rigid, and the spirochete, or flexible screws. 

This subdivision as to form is for convenience, and has no 
special pathological significance. (See Fig. I.) 

Classed according to their action the fungi are divided into 
other groups, such as Zymogenic (fermentative), Pathogenic 
(disease-producing), Chromogenic (coloring), Aerogenic (gas- 



FERMENTATION. 



forming), Saprogenic (putrefactive), Pyogenic (pu§-producing), 
Saprophytic (decomposing), etc. 



CHAPTER III. 

FERMENTATION. 



A ferment is any substance which has the ability to bring about 
the molecular oxidation and decomposition or disintegration of the 
carbohydrates and proteids, or nitrogenous and albuminous com- 
pounds. As these are the substances which are chiefly concerned 
in the composition of organic matter, it will be seen that the process 
is of overwhelming importance, and that without its comprehension 
the student is not prepared to consider any of the constructive or 
destructive changes of the body. 

Fermentation may be denned as the change brought about in 
such organic medium by the presence of a ferment. It is only within 
a recent period that its true nature has been comprehended. It 
was formerly ascribed to what was called catalytic action. It is 
now known to be induced by a special organism or substance, and 
its phenomena are those produced by the decomposition of the 
medium in which the ferment is growing, or exhibiting its energy. 

There are organized and unorganized ferments. The action of 
the so-called unorganized ferments does not essentially differ from 
that of the organized. In either the process consists in a solution of 
the bonds of constructive affinity and the formation of new com- 
pounds — in active molecular derangements and rearrangements. 
With the organic ferments this is brought about through the func- 
tional activities of simple individual organisms, while the inorganic 
ferments are formed by and owe their activity to a compound, com- 
plex structure, made up of functionally united organs, each display- 
ing its activities for a common purpose. 

The organized ferments are certain of the micro-organisms 
whose growth or proliferation is by the assimilation of the elements 
of the fermentable substance. This they have the power to decom- 
pose, as a cabbage disintegrates and resolves into its elements the 
soil in which it grows. 

The unorganized ferments are the enzymes, or those of diges- 



10 ORAL PATHOLOGY AND PRACTICE. 

tion. The gastric and intestinal juices, the saliva, etc., contain 
ferments that decompose and change the fermentable foods, and 
reduce them to a condition in which they may be assimilated, or 
built into tissue. 

It is only fermentable organic matter that can be thus digested 
and assimilated. Inorganic matter is incapable of fermentation, 
and hence cannot serve as food for any of the tissues of the animal. 

The classification of the fungi shows that they are as dis- 
tinctly vegetable as is a potato or a geranium. The fact that they 
belong to a different order, and are cryptogams instead of phanero- 
gams, does not change this. They require for their development 
the same essential conditions and elements. They must have the 
proper soil, or menstruum, in which to proliferate, or grow, as must 
the flowers of the garden or field. They require a proper amount 
of moisture, as does corn or wheat. They demand a fitting tem- 
perature, and are destroyed, or cease to vegetate, when that is 
either too high or too low, as are grass, trees, and shrubs. 

The media, or soils or materials in which the different species 
of micro-organisms grow, are as various as are the fungi themselves. 
Some require a sugar solution, made from the fermentable sugars 
formed by the change of starch into the so-called grape sugar. 
Some demand an infusion prepared by steeping vegetables belong- 
ing to the phanerogams. Some grow only in gelatins. Others 
exist only in the tissues, or extracts of the tissues, of animals. 

The temperature best adapted to their growth varies with the 
organism. With those that live in the tissues, that which is normal 
to the body is also normal to them. 

The growth of the organisms, although primarily from 
spores, goes on in various ways. 

Segmentation is the spontaneous division of a micro-organism 
into segments, or sections. Each is complete in itself, and each 
in turn subdivides into others. 

Gemmation is the process of proliferation by budding. This is 
the growth of one organism out of another, and its final separa- 
tion from the parent. 

Fission is the division of an organism into two or more parts 
by a constriction of its body. . This contraction gradually deepens 
until the separation is complete. 

Spore formation occurs when in certain stages of its life-history 



FERMENTATION. 



II 



an organism undergoes special changes. In these the interior breaks 
up into exceedingly minute embryos, which are liberated and 
dispersed by the bursting of the external envelope. Many of the 
organisms which at certain stages of their existence proliferate by 
means of segmentation or gemmation, after a definite time break 
up into spores. Something analogous to this exists among 



Fig. 2. 



•0838 



a, 



J. 



*gm & 



6, 






Methods of Proliferation of the Bacteria. 
a, b, c. Fission or segmentation, d, d 1 , Sporulation. e, e 1 , Gemmation or budding of 

organisms. 



phanerogams, the potato, for instance, being propagated by sub- 
division of its tubers, but in due process of time blossoming and 
forming seed-cases. (See Fig. 2.) 

The growth of micro-organisms proceeds by the decomposition 
of the medium in which they exist. They assimilate such of its 
elements as are essential to their own composition, leaving the 



12 



ORAL PATHOLOGY AND PRACTICE. 



remainder to form various waste products, and give rise to new 
combinations of such of the elements of the medium as are rejected. 
Under favorable circumstances, micro-organisms multiply with 
almost inconceivable rapidity. Cohn estimates the life-history of 
a single bacterium at an hour, at the end of which time it will 
divide into two or more. He computes that from a single indi- 
vidual, if all the circumstances were favorable, within five days the 
product might fill all the seas of the globe. 

Fig. 3. 




The Yeast Fungus. 

The proliferation of the Torula, or Yeast-plant, may be taken 
as a type of the whole process. This fungus consists of dngle cells, 
produced by division of the parent cell. (See Fig. 3.) It grows 
in sugar solutions with the greatest rapidity, but a short time being 
required for the permeation of a large mass by the product of a 
single cell. The process of making bread illustrates this. The 
housewife mixes flour, which consists of starch, that is easily con- 
verted into a fermentable sugar, with a sufficiency of water; she 
then places the product in a warm place, after having introduced a 
few cells of the yeast-plant. Here are all the elements needed for 
development — a suitable medium, sufficient moisture, and the 
proper temperature. 



FERMENTATION. 1 3 

The yeast-plant commences its growth and permeates all 
parts of the mixture. It decomposes the sugar, separating the 
oxygen, carbon, and hydrogen. It builds into itself that which 
is necessary and rejects the other atoms, which immediately enter 
into new combinations, forming as by-products, alcohol and carbon 
dioxide. Wherever a cell of the yeast-plant is formed, there is left 
as by-products a bit of alcohol and a minute globule of carbon 
dioxide gas. The latter distends the dough, or causes it to "rise." 
When this is completed it is placed in the heated oven, with the 
result that the yeast-plant is killed, and the dough is fixed, or cooked, 
and becomes bread. Beer-making is an analogous fermentation. 

The alcoholic fermentation is that which results in the formation 
of alcohol as one of the by-products. The fermentation of grape 
juice, and the formation of alcohol from the starch of various 
grains, belong to this class. The growth of the ferment produces 
alcohol, which is held in solution in the water, and is then distilled 
off by its evaporation at a comparatively low temperature. 

The acetous, or acid, fermentation is the growth of yet another 
organic ferment, that leaves as a by-product an acid. Of this char- 
acter is the organism Mycoderma aceti, or the so-called "mother" 
of vinegar. It decomposes a sugar solution, and produces acetic 
acid as a by-product. In like manner, through the action of dif- 
ferent organisms, are produced all of the very many true organic 
acids. Others of the fungi produce gelatin, and yet others various 
gases. 

The putrefactive organisms decompose nitrogenous matter by 
their growth, with the evolution of offensive gases as their by- 
products. All the fungi grow at the expense of the medium in 
which they exist, and through its decomposition, or molecular 
change. Their by-products vary with the organisms themselves, 
and, as in the case of the ptomains and toxins, are sometimes of 
such a poisonous nature as to induce diseased or pathological 
conditions. 

Some of the fungi grow only in the presence of air or oxygen, 
and hence are called "aerobic," while others nourish in tissues or 
cavities to which air has no access, and are called "anaerobic." 

They are also said to be "obligate," those whose demand for 
the presence or absence of oxygen is imperative and peremptory, 
and "facultative," those which flourish best in one condition or the 



14 ORAL PATHOLOGY AND PRACTICE. 

other, though able to proliferate either as aerobic or anaerobic 
organisms. 

The bacteria generally are self-limiting. Their own by- 
products are fatal to them, and when the medium in which they 
are growing becomes sufficiently contaminated the organisms will 
perish. Thus, when an acid-producing organism has made its 
menstruum sufficiently acid, it will die unless the acid is neutralized 
by an alkali, in which case it goes on proliferating, provided the 
pabulum, or nutritive supply, is not exhausted. All the ferment- 
able material in a solution may be used up and decomposed, so that 
there will no longer be food for the organism, in which case it will 
die out. 

One organism may destroy and supersede another by its superior 
activity and power of decomposition, or through its production of a 
chemical compound that is fatal to the first. The brewer must use 
the most scrupulous care to prevent the intrusion of a strange 
organism into his infusion, or the result may be an acid instead of 
an alcohol, with the consequent souring of his beer. The housewife 
"scalds" the pans and other utensils in which milk is kept, and 
submits them to strong sunlight that all infective or acid-producing 
organisms may be destroyed. 



CHAPTER IV. 

BACTERIOLOGICAL PATHOLOGY. 

From the standpoint of the pathologist, the micro-organisms 
may be divided into several classes, according to their action upon 
the animal economy. 

Pathogenic microbes are those whose proliferation or whose by- 
products cause specific pathological changes; they are disease-pro- 
ducing. 

Saprogenic organisms are those which cause putrefaction, or 
the decomposition of nitrogenous matter, with the solution of 
ammonia and hydrogen sulphide gases. 

Pyogenic micro-organisms induce suppuration, or the forma- 
tion in living tissues of pus, which is the fluid produced in the 
process of suppuration. 



BACTERIOLOGICAL PATHOLOGY. 1 5 

Saprophytic bacteria are those which live only on dead matter; 
they induce decomposition and disruption of the elements of the 
functionless organic matter in which they proliferate. 

For the study of any of these micro-organisms it is necessary 
to make pure cultures, obtained by implanting them, as they are 
mixed with others, in the best culture media, and separating out 
and replanting selected colonies until everything has been elimi- 
nated save that which it is desired shall be investigated. They 
cannot be identified by a microscopic inspection of the organisms 
themselves, — they are too minute for this purpose. But by observa- 
tion of the phenomena of their growth, and by tests of their 
products, as well as by staining them with certain aniline dyes which 
do not affect their surroundings, they may readily be differentiated, 
or distinguished from other organisms. 

To produce a pure culture of any organism, an incubator, 
or growing-chamber, is required, in which the exact amount of 
moisture and the proper temperature may be maintained prac- 
tically unchanged for an indefinite period. 

Micro-organisms penetrate everywhere that air can go. So 
innumerable are the different species, and so minute their size, 
the spores of many of them being invisible even beneath the 
highest powers of the microscope, that everything conceivable 
becomes infected with the seeds of disease and decay. A single 
species has in the past caused greater alarm and devastation than 
all the armies of the most pitiless conqueror who ever ravaged the 
earth. The bacillus that produces cholera has decimated nations. 
The various plague bacteria have invaded great cities and de- 
stroyed every second person. They have defeated and dispersed 
invading armies, and have stayed the march of destroying hosts. 
The bubonic plague, which is the result of the growth of a patho- 
genic organism, has, in the past, swept away one-third of the 
population of Europe in a single invasion. 

A few of the most fatal of the maladies which are the direct 
result of the growth of some special organism, and which are 
therefore contagious in their character — the so-called zymotic 
diseases, of either epidemic or endemic origin — are the following: 
Cholera, Diphtheria, Relapsing Fevers, Leprosy, Typhoid Fever, 
Syphilis, Smallpox, Septicemia, Osteomyelitis, Tuberculosis, 
Lupus, Tetanus, Glanders, Actinomycosis, Malignant Pustule, 



1 6 ORAL PATHOLOGY AND PRACTICE. 

Gonorrhea, Leucorrhea, Scarlet Fever, Mumps, Meningitis, Ery- 
sipelas, Carbuncle, Pneumonia, Rabies, Anthrax. 

Late investigations have shown that the one malady that 
in this country is responsible for more deaths than any other, tuber- 
culosis or consumption, is as communicable as smallpox, and can 
only be acquired through infection. Its period of incubation, or 
development, is longer than that of most infectious diseases, but it 
can be as certainly stamped out by isolation, disinfection, and the 
use of antiseptics as can cholera, that former scourge, which in the 
light of our modern knowledge of bacteriology is now so readily 
controlled. 

Were there no means of resisting the invasion and growth of 
the special organisms which induce these diseases, and of impeding 
their multiplication, they would inevitably depopulate the earth. 
It has already been asserted that they are self-limiting in their 
proliferation, through their inability to exist in the presence of 
their own waste products. They may also exhaust the soil or 
medium in which they grow, and thus circumscribe their own 
multiplication. 

The most material factor in the prevention of the increase of 
the zymotic diseases is the resistive power of healthy animal func- 
tion. Under ordinary circumstances, the human body successfully 
reacts against infection, and prevents undue proliferation of patho- 
genic organisms. If, however, the bodily tone is depressed 
through malnutrition, by unsanitary conditions, by fatigue or 
exhaustion, or because of functional disturbances, the resistive force 
of the body is so much weakened, and the conditions favorable to 
the growth of the disease fungi so augmented, that they multiply 
to an extent sufficient to bring about that pathological condition 
which accompanies their invasion. 

Conclusive experiments upon animals have demonstrated this. 
Rabbits are immune to tubercular infection under ordinary condi- 
tions. Twelve of these animals were selected; six of them were 
kept for some time in a dank and noisome cellar, and insufficiently 
fed upon unwholesome food. The other six were kept in complete 
sanitary condition, in light and airy rooms, and were fed with 
the best food. At the end of a definite period each was inoculated 
with Bacillus tuberculosis. All of the first six took the infection 
and died of it; the six whose bodily tone had been preserved by 



BACTERIOLOGICAL PATHOLOGY. 



17 



pure air and good food retained their immunity, and successfully 
resisted infection. 

Twelve rats were selected, and six of them placed in a 
revolving wheel that forced them to run at a rapid gait for a 
considerable time. The other six were allowed to remain in a 
quiet place, where they would not be annoyed or irritated. When 
the first six had been forced to run until they were exhausted, all 
the twelve were inoculated with an organism from which under 
ordinary circumstances rats have exemption from infection. 
Those whose resisting powers had been reduced by extreme 
fatigue and exhaustion took the contagion and died, while the 
others were unaffected. 

Fig. 4. 




Cu 





Leucocytes. 
a, b, c, Ameboid forms assumed by them, with pseudopodia. a 1 , b 1 , Ingestion and 

digestion of bacteria. 

The resistive power of the human body, according to Metch- 
nikoff, is largely, though not exclusively, inherent in the ameboid 
white blood corpuscles, which in a state of health envelop and 
digest the bacteria. (See Fig. 4.) When these are not fully 
formed in the system, when they are diminished in number or 
reduced in functional activity, the infective organisms may obtain 
such preponderance as to overcome all resistance, and run their 
course until they produce death, or become self-limiting through 
the formation of their own by-products and the exhaustion of the 
media in which they grow. 

The bacteria are greatly multiplied in the presence of any 
putrefactive or decomposing' material. Hence all decaying matter 
should be destroyed as far as possible, by some quicker and more 

3 



1 8 ORAL PATHOLOGY AND PRACTICE. 

hygienic process than its decomposition by the fungi. Sanitary 
conditions imply the removal of all infective matter, and modern 
hygiene is mainly the study of how best to accomplish this. Such 
progress has been made within the past generation, that the 
average period of human life has been lengthened several years, 
almost entirely through the ability of sanitarians to control the 
multiplication of disease spores. 



CHAPTER V. 
SEPTIC AND ASEPTIC CONDITIONS. 

The state of infection by disease-producing, or putrefactive, 
organisms is called a septic condition, and whatever tends to 
combat this is said to be antiseptic in its character. A state of 
freedom from all degenerative organisms is an aseptic or sterile 
condition, and it may be brought about by various agencies, either 
of a physical or medicinal nature. As moisture is one of the 
elements necessary to the growth of the fungi, it may be readily 
comprehended that its entire removal will stop all development. 
Hence dry climates or desiccated conditions are unfavorable to the 
growth of bacteria. On the elevated plains of South America beef 
is indefinitely preserved by drying it in the sun. In other countries 
the same thing is accomplished by artificial evaporation. 

The proper degree of temperature is essential to growth, and the 
raising or lowering of this beyond a certain point will limit or 
prohibit it, a definite amount of heat being sufficient to destroy all 
organisms and render sterile any substance whatever. Upon the 
tops of high mountains, above the line of perpetual snow, the 
bacteria are almost non-existent. The cold weather of our freezing 
winters stops the spread of the most virulent zymotic diseases, and 
fermentation and putrefaction cease, except in the presence of 
artificial heat. 

There are also certain drugs that have the ability to destroy 
or prevent the growth of septic organisms. 

Those that are fatal to the bacteria and their spores are called 
Germicides. 



SEPTIC AND ASEPTIC CONDITIONS. 19 

Those that limit and prevent their growth are classed as Anti- 
septics. 

Those that decompose or remove the by-products of infection 
are called Disinfectants. 

Those that either mask or remove the offensive smells of putre- 
faction are denominated Deodorants. 

The most effective of all the agents used for sterilization is 
heat. The temperature of boiling water (212 F., ioo° C.) is fatal 
to many of the septic organisms. But as the spores of some of 
them may successfully withstand this, it cannot in all cases be de- 
pended upon. Continuous boiling for some time will be sufficient 
tc destroy most of the organisms contained in water. Yet, if it is 
to be positively sterilized, it must be distilled. If an instrument is 
passed through the flame of burning gas, or of an alcohol lamp, it 
will be made positively sterile, but this is in some cases impracti- 
cable, because it will destroy the usefulness of steel tools by draw- 
ing the temper. The tissues of the body, and of most organic mat- 
ter, cannot be raised to a temperature sufficient to insure an aseptic 
condition, and hence we are compelled to depend upon germicides, 
antiseptics, and disinfectants in the treatment of septic conditions. 

Most germicides are to a greater or less extent antiseptic in 
their nature. That is, agents that have the power to destroy 
germs will also prevent their growth. Many of the antiseptics 
are at the same time germicides and disinfectants, and vice versa. 
In the selection of drugs for medicinal purposes it is necessary 
to consider something more than their germicidal or antiseptic 
qualities. One that is a virulent poison cannot with safety be 
administered internally, nor can one that is a cauterant be used 
on delicate tissues. It is therefore necessary to comprehend the 
therapeutics of antisepsis, and to select the remedy to be used in 
full view of these facts. 

Pure germicides are not always demanded in actual practice. 
If a proper disinfectant is first employed to remove the products of 
sepsis, and to cleanse the infected tissues, it will commonly serve 
every purpose. Most of the disinfectants that are in general 
remedial use not only remove or decompose the products of infec- 
tion, but are fatal to the germs themselves, and to the extent of their 
antiseptic influence inhibit or prevent their growth. Hence it is 
not ordinarily necessary to follow the use of a disinfectant like 
peroxide of hydrogen by a strictly germicidal or antiseptic agent. 



20 ORAL PATHOLOGY AND PRACTICE. 

The necessities and conditions of oral practice are such as to* 
exclude many disinfectants, unless they are securely sealed up 
within the cavity of a tooth. If they are of a caustic nature, they 
will induce complicating lesions. If they are specially toxic, or 
poisonous, they may bring about serious derangements. There- 
fore, in their selection, the judicious practitioner will exercise great 
care, and choose those which, with the highest degree of effective- 
ness in their special action, at the same time are not injurious to 

Fig. k. 






The Comma Bacillus of Cholera. 



other tissues. In this respect carbolic, or phenic, acid, a drug that 
has been in most common use in oral practice, is exceedingly 
objectionable. 

The following list of remedies, formulated by Prof. W. D. 
Miller from personal experimentation, and first published in the 
"Independent Practitioner" for June, 1884, indicates their relative 
antiseptic power, but is not by any means intended as a guide for 
choice in administration. It gives the dilutions in which each 
will, under favorable circumstances, limit the growth of micro- 
organisms: 



SEPTIC AND ASEPTIC CONDITIONS. 



21 



Mercuric Iodide, 

Mercuric Bichloride, 

Silver Nitrate, 

Hydrogen Peroxide, 

Tinct. Iodine, 

Iodoform, 

Naphthalin, 

Salicylic Acid, 

Oil Mustard, 

•Benzoic Acid, 

Potassium Permanganate, 

Oil Eucalyptus, 

Carbolic Acid, 

Hydrochloric Acid, 

Borax, 

Arsenic, 

Zinc Chloride, 

Lactic Acid, 

Sodium Carbonate, 

Listerine, 

Alcohol, 

Potassium Chlorate, 
The disinfectants act chiefly through their ability to decompose 
offensive products. This is usually brought about by the presence 
of free oxygen, or that which is held in loose combination. Chlorin- 
ated solutions are effective through their ability to decompose 
water, thus setting free one or more volumes of oxygen, which is 
really the agent of decomposition. Hydrogen peroxide is very 
widely employed in oral practice, because it so readily parts with 
its extra volume of oxygen. Pyrozone is a more permanent and 
abiding preparation of nearly the same character. Electrozone, 
which is a decomposed solution of ordinary sea-water, is very 
effective, and has the advantage of being entirely innoxious. It 
may be swallowed, or used on the most delicate tissues, without ill 
effects. It is produced by an electrolytic current, which decomposes 
the chlorides and bromides of the salts, changing them into hypo- 
chlorites and bromites, and these are most effective disinfectants. 

Deodorants are not necessarily chemical agents. They may 
merelv be able to absorb noxious matter. An excellent one is 



i part in 200,000 
100,000 
50,000 
8,000 
6,000 
5,000 
4,000 
2,000 
2,000 
1,500 
1,000 
600 
500 
500 

350 
250 

250 

125 

100 

20 

10 

8 



22 ORAL PATHOLOGY AND PRACTICE. 

pulverized charcoal, which has the power to absorb a number 
of times its own volume of deleterious gases. It thus acts also 
as a disinfectant. The deodorants most commonly employed by 
oral practitioners are drugs of such penetrating, though pleasant, 
perfume that they cover and mask the odors of putrefaction, though 
without in any way neutralizing or decomposing them. It is need- 
less to say they have no special therapeutic value. 

Detergents are cleansing remedies which are sometimes in de- 
mand. They have no particular medicinal virtue, but remove 
certain superficial deposits from tissue surfaces, or from wounds, 
ulcers, etc. Pure water is excellent for this purpose, or a solution 
of borax, of common salt, or of soap may be used. 

Suppuration is primarily the breaking down of the product 
of inflammation, and its infection by a special microbe. Whether 
the breaking down is due to the organism, or vice versa, was long 
a disputed question*. More recent investigations have established 
the fact that it is infection that brings about the devitalization of 
the blood corpuscles and the production of pus, and yet it has been 
demonstrated that it is possible for pus corpuscles to be produced 
without the presence of bacteria. Such a condition must, however, 
be unusual, and it cannot present all the characteristics of the sup- 
puration induced by pyogenic organisms. 

Ordinary pus is composed of certain nucleolar corpuscles that 
are indistinguishable from the white blood cells, and which are 
supposed to be these dead leucocytes, the extravasated serum of the 
blood, and such broken-down tissue cells as may exist in a certain 
state of degeneration. This material is found infected with certain 
pyogenic fungi. The formation and presence of pus is accompanied 
with the pyogenic fever, and its presence in the tissues may also, 
under favorable circumstances, be determined by fluctuation beneath 
the fingers. When it is formed within the tissues it makes its way 
to the surface by the readiest route, that of least resistance, through 
the process of rotting or breaking down of the obstructing tissue, 
and thus forms an abscess. The process of suppuration is essen- 
tially one of extrusion, or expulsion of effete or dead matter. That 
inoculation, or infection of healthy tissue with the suppurative 
bacteria, will induce the formation of pus and the production of an 
abscess is thoroughly established. Hence, in all curative processes 
it is essential to use the utmost care to avoid infection, and all the 



SEPTIC AND ASEPTIC CONDITIONS. 23 

modern methods of antiseptic surgery are built upon the ability 
to control the growth of septic organisms. 

All of the pathogenic and pyogenic bacteria are very easily 
communicated, either by direct contact and contamination, or 
through their spores, which may be floating in infected air. 
Modern surgery is superior to that of a few years since in the re- 
sults obtained; surgeons have learned how to avoid and guard 
against septic infection. It is now known, for instance, that if 
erysipelas once makes its appearance in the surgical ward of a 

Fig. 6. 




Bacillus of Diphtheria. 



hospital, mere exposure to the contaminated air will be likely to 
induce erysipelatous inflammation in any patient, but especially 
those in an atonic or debilitated condition. The bacillus of diph- 
theria has been known to be carried by a garment that had been 
repeatedly washed after infection. (See Fig. 6.) 

Infection may be carried upon the hands, in the clothing, or by 
instruments and implements. The surgeon who would now attempt 
even minor operations without the most strict aseptic precautions 
would be deemed unfit to practice his profession. His hands must 
be most thoroughly washed, all impurities removed from beneath 
the nails, and they must finally be carefully drenched with a steriliz- 



24 ORAL PATHOLOGY AND PRACTICE. 

ing solution, that no contaminating fungi may be carried to a 
wound. Every instrument used must be kept in a sterilizing solu- 
tion, and sponges and lints must be needfully rendered non-infec- 
tious. The ordinary clothing must be covered with clean linen 
garments, that are less liable to carry infection than woolen, and 
every article used must be scrupulously clean. 

The dentist should always wear a clean linen coat at the chair. 
Any woolen overgarment must soon become thoroughly impreg- 
nated with disease germs, and thus he may carry contagion to suc- 
cessive patients. He himself and the most healthy and vigorous 
of them may be able to resist infection, but those who are weak and 
anemic and who do not possess the same withstanding ability may 
be seriously affected. Omission of these proper precautions will 
also be likely to result in infection and suppuration of the wounds 
which may be accidentally or are necessarily made, and even gan- 
grene may be the consequence. 

Every operative dentist, or oral surgeon, needs to exercise espe- 
cial care in this direction. There is no mouth that does not contain 
some species of bacteria. Indeed, the presence of some of them 
seems essential to perfect health, because they exercise a distinct 
diastatic function, and thus in normal conditions may assist in the 
process of digestion. The human mouth presents all the conditions 
favorable to the growth of the bacteria, because the debris from 
different kinds of food, especially of starches, is always present. 
The diastatic action of the saliva converts these into fermentable 
sugars, and thus presents the best medium for the proliferation of 
very many of the bacteria. Moisture exists in sufficient quantity, 
and the temperature is exactly that best suited to their development, 
and it is maintained at a point as constant as could be secured in the 
most perfect incubator. Indeed, the human mouth is a more perfect 
growing-chamber for the breeding of germs than any thai the 
ingenuity of man could possibly devise. Not only is the tempera- 
ture uniform and the media and moisture at the best, but fresh 
pabulum is constantly added, while the by-products are promptly 
removed and neutralized, so that there is no limitation of growth 
through their formation. 

The importance of every antiseptic precaution on the part of 
the practicing dentist cannot be overestimated. He frequentlv 
meets with pus in the oral cavity, with gangrenous pulps in teeth, 



INFLAMMATION : ITS GENERAL CHARACTERISTICS. 25 

and his instruments are almost constantly infected with septic 
organisms. These may be deeply buried beneath the debris 
between the leaves of burs and the serrations of files, so that 
mere rinsing in a sterilizing fluid will not sterilize, and infec- 
tion of perhaps the most loathsome character may be carried to 
the mouth of the next patient, unless scrupulous care is used. 
It is something more than a professional blunder when an operator 
will work in the presence of pus, or any infection, without subse- 
quently cleaning and sterilizing in the most thorough manner 
every instrument employed, by means of a specially devised 
apparatus, and the use of disinfecting agents, such as bichloride 
of mercury, carbolic acid, potassium permanganate, formalin, and 
other solutions. 



CHAPTER VI. 

INFLAMMATION: ITS GENERAL CHARACTERISTICS. 

A careful study of the etiology, symptomatology, and pathol- 
ogy of the inflammatory process is of the first importance to the 
student in dental medicine, because with bacteriology it forms the 
basis of most degenerative changes. Nor is it only concerned in 
retrogression. If hyperemia is accepted as one of the early stages 
of the inflammatory process, it is an important factor in many 
physiological and progressive metamorphoses as well. Wounds 
are healed and lesions repaired through its agency in some of its 
many phases; it is thus an element in the building up, as well as in 
the tearing down of tissue. There are emergencies in which the 
oral surgeon or physician desires to invoke its aid, and he some- 
times deliberately incites its action. But to reach the success at 
which he aims he must be able to control and -limit it, to impede 
its action here and to further its energy there, and at all times to 
check it before it shall reach a degenerative or infective stage. 
Unless the practitioner has a fair comprehension of this important 
process, he will always be at work in the dark, and his treatment 
of most diseased oral conditions will be wholly empirical and 
experimental. The student will not be able intelligently to investi- 
gate any of the disorders to which he hopes successfully to 
minister, without a careful preliminary study of inflammation. 



26 



ORAL PATHOLOGY AND PRACTICE. 



The most advanced of modern pathologists, while they have 
extended the field of observation, have materially simplified the 
nomenclature. They recognize many added phases which the 
inflammatory process may assume, but in the light of the most 
modern bacteriological research they acknowledge but one dis- 



Fig. 7. 



&£>, 



Od.- 



N.T.- 



B.V.. 



' /"V.,. i y 






' ' ! * >\^<'' : ^Jjtt ' J * ' 'K 


w$xi 




'•4 ' I' M' wi '-\ 






1™ 1/ /f\r " W\ ^K 




* * *r#- 1&^A / '/ J>' 


';, ,',-. . - -„„■-, .,,;■;,«„ ,„i-UrJ 


\ \ '.& I ' 5 L ' iti v 11 ' '' ftiii As 



■JV.^ 



.<?•<? 



Section of a Tooth-Pulp. (Burchard, after Rose and Gysi.) 

B.V, Principal bloodvessels. C, Capillaries. N. T, Principal nerve trunk. N.F, fibrillae 
of nerves. Od, Odontoblasts. S.D, Secondary dentine. C.G, Masses of calco-globulin. 



tinct form, that being the infective. Up to the point of invasion by 
septic organisms and the commencement of the deteriorative or 
destructive process, they denominate the condition one of hyperemia. 
Until disease germs are communicated they declare there can 
be no breaking down of tissue, or of the elements of tissue. There 
may be failure to organize the embryonal constituents, but the 



INFLAMMATION I ITS GENERAL CHARACTERISTICS. 2/ 

disorganization of that which has once been constructed can only 
take place after infection. Hence, according to their views, all of 
the early symptoms and phenomena which are usually classed as a 
part of the inflammatory process belong to the distinct condition 
hyperemia, and are indicative only of a local plethora, or congestion. 

In this conception, and according to this nomenclature, 
inflammation is essentially a destructive process, and its initial 
point is the beginning of the disorganization of tissue. This 
hypothesis emancipates us from the old and absurd nomenclature, 
under which every different phenomenon exhibited by what must 
necessarily be a single process was given a separate name and 
classed as a distinct form of inflammation. Some writers have 
specified as many as fifteen kinds of this process, and treated each 
as a separate pathological condition. There has been no identity 
of view, and no harmony in description or terminology. There 
has been no universally accepted theory which might be adopted, 
but each pathologist has been in one sense a law unto himself, 
and has instructed according to his own views. 

If the most modern hypothesis shall be generally adopted, 
there is no doubt that it will materially simplify pathological 
instruction, and reduce to a comprehensible system much that 
has heretofore been incongruous and unintelligible. But in the 
preparation of a book to be used in teaching, extreme views should 
not precipitately be adopted. They are not likely to be in har- 
mony with the teachings of the other departments of a school, 
they are in conflict with instruction already given and with 
preconceived ideas, and until they can be generally accepted tend 
to produce confusion in the mind of the student, and are preju- 
dicial to that unity in theory and consecutiveness in thought 
which are essential to good tuition. It is infinitely better that 
the student in college should be given but one hypothesis, rather 
than a number of conflicting theories. When he is familiar with 
that, he may in practical life leave its limitations and modifications, 
and become acquainted with other views. 

This work, then, while fully recognizing the reasonableness 
of the most modern theories concerning inflammation, will not 
fully adopt their nomenclature, but will follow the usually accepted 
views, modified to a certain extent by the indisputable facts estab- 
lished by the most modern research. 



28 ORAL PATHOLOGY AND PRACTICE. 

But, while making this concession, it must not be understood 
that it accepts or approves the infinitesimal division of that which 
is really indivisible, and that it will consider every accidental phase 
of that pathological condition which is denominated inflammation 
as a distinct and separate disease. There can be no essential dif- 
ference between an inflammation of the pulp of a tooth, or its 
pericementum, and the same degenerative process in the tissue of 
the tongue, or the brain, or the lungs. It is true that each may 
assume certain definite phases, and may exhibit varying phenomena 
or symptoms, but these are induced by structural modifications, 
or by differences in the environment and surrounding conditions. 
The pathology is essentially identical ; the same causes produce it 
in either case, and though we may denominate the special phe- 
nomena as exhibited pulpitis, pericementitis, glossitis, or pneu- 
monitis, according to the location, we should not look upon them 
as separate, distinct, and diverse diseases. The same general 
treatment will be pursued in all cases ; the same remedies are appli- 
cable, modified only by the modifying conditions or surroundings. 
Hence in the general study of inflammation we should consider it 
as always the same degenerative process, and carefully avoid the 
unnecessary multiplication of terms. 

Inflammation may be defined as a disturbance of nutrition in 
a tissue or organ, primarily characterized by hyperemia and accom- 
panied by certain definite symptoms. Its proximate cause is irri- 
tation of some kind, producing nervous shock, either direct or 
reflex, which is conveyed through the vaso-motor system to the 
capillaries and first manifested by changes in those vessels, thus 
modifying the nutritive blood current. That the student may com- 
prehend this, it is necessary clearly to define some of the terms 
used, and to indicate in what sense they are employed. 

Plethora is that state in which there is an abnormal fulness of 
the bloodvessels ; a superabundance of blood ; an undue increase 
in the entire mass of the blood in the system. 

Anemia is the converse of this. It is a state in which there is a 
deficiency of the blood as a whole, but especially a lack of the red 
blood corpuscles. It is therefore a condition of depression of the 
tone of the system, and of enfeebled nutritive ability. 

Hyperemia is a local plethora or congestion of blood. Its special 
seat is in the capillaries. 



INFLAMMATION 



ITS GENERAL CHARACTERISTICS. 



29 



Ischemia is a local anemia. It implies a lack of nutrition in a 
part, as anemia does in the general system, because the supply of 
blood is for some reason insufficient. 

Hyperemia implies an alteration in the velocity of the cnrrent 
of the blood in both veins and arteries. It also includes a variation 
of the bloodvessels in their character or tone, their nutritive power 
being modified. There is a change in the condition of the coats of 
the smaller arteries and veins ; they assume a state either of tense- 

Fig. 8. 




Cementum, showing the Cementum Corpuscles, or Laccnve, with the Canaliculi. 

(Broomell.) 

ness or laxity that is not normal to them. They become turgescent. 
The color of the blood in the veins is changed by modifications of 
nutrition. It- is no longer of a dark or venous color, but more nearly 
approaches a bright arterial hue, due to its inability to perform its 
true function and exchange its oxygen for the carbon dioxide that 
is the result of the degenerations of tissue due to wear. There is a 
partial obstruction of the current in the arterioles, and they may 
even begin to pulsate with the larger arteries. Both veins and 
arteries become distended with the increased flow of blood. The 



30 ORAL PATHOLOGY AND PRACTICE. 

blood corpuscles are greatly increased in number and modified in 
tone. 

If the irritation that has produced this condition in the tissues 
is not continued, the disturbance will be but temporary, and will 
soon subside. The system recovering from the nervous shock, the 
bloodvessels will soon regain their normal tone, the vascular fluid 
will begin to flow in its wonted manner, the congestion of the 
capillaries will be relieved, and the hyperemic condition will pass 
away. 

It has already been affirmed that it is the nervous shock pro- 
duced by the action of some irritant which induces the change in 
the condition of the arteries and veins that accompanies active 
hyperemia. Technically it is not the bullet in the heart that kills ; 
it is the nervous shock caused by the irritating bullet. The 
knife stab may injure certain tissues that are not vital; but in so 
doing it may produce a nervous impression that is so profound as 
materially to interfere with the processes of life which are vital, 
function may cease, and that is death. It was not the wound that 
killed, but the markedly depressing influence which it induced upon 
organs themselves untouched. It is necessary to keep this distinc- 
tion carefully in mind in the consideration of inflammation. 

Shock may be produced by either direct or reflex nervous action, 
and it may be immediate or delayed. 

By direct, we mean the irritation that is produced by actual injury 
to the terminal nervous -filaments themselves. Thus a blow upon the 
cheek will induce a redness, or hyperemia in the capillaries of the 
tissue that received the irritation, and whose nerve filaments were 
really harmed or shocked by the impact. 

By reflex nervous action, we mean that in which the impulse is 
reflected, or carried by one set of nerves to another set, thus pro- 
ducing its effect at a distance from the seat of irritation. The influ- 
ence of an irritant may be carried by an afferent, or sensory nerve, 
to some great center, where it will be transmitted to an efferent, or 
motor nerve, and the stimulus carried along its course until it 
reaches the tissue supplied by it, and it may be upon this that the 
characteristic effect will be indicated. Or the effect of the irritating 
agent may be received by one afferent nerve and reflected to another 
of the same system, the subjective sensation, with the local effects, 
thus being made manifest at some distance from the point of injury. 



INFLAMMATION: ITS GENERAL CHARACTERISTICS. 31 

The blush that is brought to the cheek of the sensitive young maiden 
by an indelicate remark is the same kind of transient hyperemia that 
is produced by a blow of the hand. Yet in the former case there is 
no real impact, no positive injury, no actual lesion of any kind. 
But the hyperemia will probably be more pronounced and marked 
than when the nervous action is direct. The face will blanch 
under the influence of fear, when no direct impact could produce 
this effect. The hair will stand erect through reflex action caused 
by intense alarm or terror, a state that no voluntary action could 

Fig. 9. 



■^ ■■ :' , ■ ■■■■■■'■■ ■ ■ 








Structure of Dentine, showing the Branching of the Dentinal Tubuli. 

bring about. People sometimes drop dead at the communication of 
profoundly affecting news, which acts in a reflex manner. Indeed, 
instant functional cessation and death are more complete and fre- 
quent in cases of shock from reflex than from direct injuries. The 
influence of external and surrounding impressions upon sick people 
will not infrequently completely neutralize the effect of medicinal 
agents. 

Profound anesthesia cannot readily be obtained in people with 
unusually responsive nerves, unless external irritation and inter- 
ference is cut off. It becomes necessary in such instances to remove 
all exciting causes and establish complete quietness about them. 



32 ORAL PATHOLOGY AND PRACTICE. 

It would appear, then, that of the sources of irritation that may 
produce hyperemic conditions, those that are derived through reflex 
nervous action are the more important, and should be most carefully 
guarded against. 



CHAPTER VII. 



CHANGES ATTENDING THE INFLAMMATORY 
CONDITION. 

The changes in the veins and arteries that induce a condition of 
hyperemia are produced through the vaso-motor nerves. These 
are derived both from the cerebro-spinal and the great sympa- 
thetic systems. They are the non-medullated terminal filaments 
whose special function it is to govern and keep in proper relation 
the coats of the bloodvessels to which they are distributed. Upon 
the larger vessels they form intricate plexuses, sending out single 
filaments, or bundles of filaments, which twine about the vessels, 
penetrate their external coats, and are principally distributed to the 
muscular tissue of the vessel, and by their action in contracting or 
relaxing the artery or vein they govern the amount of the blood- 
flow. 

There are presumably two kinds of nerves in the vaso-motor 
system, one being the constrictors and the other the dilators. It 
will readily be seen, then, that either may be excited and the caliber 
of the vessel modified accordingly. Nor is the amount of blood 
necessarily and completely gauged by the question as to whether 
it is the dilators or the constrictors that are excited to action. There 
may be a lessening of the caliber but a retention of the elasticity of 
the muscular fibers that will result in a great increase of the velocity, 
and this may have a tendency to wash away anv obstructions in the 
blood channels. On the other hand, there may be a dilatation with 
a loss of tone and a complete rigidity of the muscular coats that 
will eventuate in a reduction of the velocity as well as in the amount 
of blood conveyed. 

There may be a contraction of the vessel, with a condition of 
such tonicity as will greatly augment the velocity of the circula- 
tory fluid, or there may be almost a complete stagnation of blood 
in a greatly relaxed artery or vein. Niagara river at its head is 



CHANGES ATTENDING THE INFLAMMATORY CONDITION. 33 

nearly two miles wide. At the Whirlpool rapids below the Falls it 
is contracted into a narrow channel but a very few hundred yards 
across. Yet a somewhat larger amount of water pours through the 
gorge of Niagara than flows past Buffalo. Lake Ontario is but a 
great expansion of Niagara river, augmented by tributary streams. 
At Buffalo the Niagara is a smooth and steadily flowing current 
which subserves a thousand useful purposes. The Whirlpool rapids 
is a tumultuous, riotous torrent, suggestive ouly of death and de- 
struction. Lake Ontario is a sluggish, lethargic expanse, almost 
without current. Under the influence of the vaso-motor nerves, 
and according to their tonicity or lack of it, the blood current in the 
capillaries may be a steadily moving, gentle, nutritive current, a 
violent, turbulent, destructive torrent, or a phlegmatic, stagnant 
expansion. 

It may readily be seen, then, that the tone of the walls of the 
vessels has very much to do with the blood supply. Through the 
reaction of the vaso-motor nerves, the very character of the coats 
of the capillaries may be materially modified, so that instead of 
retaining their contents they allow an undue emission througti the 
meshes. The different coats may become so relaxed that through 
their walls the red or the white blood corpuscles, or the serum of the 
blood, may readily exude, and so pass out into the surrounding 
tissues, infiltrating them and producing certain symptoms which 
attend the condition that is commonly called the inflammatory 
state. All these changes must be massed in the consideration of 
the inflammatory process. 

The first stage is hyperemia, or an increased blood supply, 
through modification of the caliber of the coats of the bloodvessels. 

The second stage consists in the further changes in the condition 
of the coats of the vessels, by which they become so modified as no longer 
perfectly to retain all their contents. 

The third stage is the modification produced in the tissues 
through the extruded contents of the bloodvessels, for the elements 
having once passed out cannot enter them again, but must be other- 
wise disposed of. This stage necessarily includes the degenerative 
processes taking place in the products of inflammation which result 
from infection. 

It should be apprehended that the mere change in the caliber 
of the vessel forms no necessary part of the inflammation, which 

4 



34 



Or.AL PATHOLOGY AND PRACTICE. 



may terminate with the simple hyperemia. But the second change, 
that in the vessels, which so modifies them that they no longer 
retain their contents, produces a more profound impression and 
materially affects the tissues nourished by them. When the 
extravasated matter becomes infected with pathogenic or pyogenic 




Enamel Highly Magnified, showing the Characteristic Prisms. 
(J. L.Williams.) 

micro-organisms that impression is intensified, and degenerative 
processes are set up. This is an active state of inflammation, in 
which all the nutritive processes of the part are engaged. 

There are certain symptoms that are peculiar to inflammation 
and which always attend it in a greater or less degree. They are 
heat, redness, swelling, pain, and usually a general febrile condition. 



CHANGES ATTENDING THE INFLAMMATORY CONDITION. 35 

The violence of these will depend upon the gravity of the disturb- 
ance and the character of the tissue affected. Other things being 
equal, the more vascular it is, the greater the blood supply, the 
more pronounced will be the symptoms. 

The first of these, heat, is due to a number of factors. The 
deeper portions of the body have a higher temperature than those 
that are superficial and are exposed to external cooling influences. 
When the blood quickly reaches the periphery it will lose less of its 
vital heat than when it makes its way more gradually. Hence, in 
the increased velocity of inflammation, the surface has more of the 
heat of the internal portions of the body. 

Again, this very velocity generates a certain amount of heat by 
the increased friction. There is also some increased oxidation, 
and this adds to the higher temperature. All of these factors 
together account for the increased local heat of inflammation. 

The redness is due to the hyperemic condition, the increased 
amount of blood in the part, and the unchanged color of the venous 
circulation. The intensity of the change will depend upon several 
factors. The amount of the local disturbance, the thickness of the 
superimposed tissues and their degree of translucency, will all have 
an influence. Persons with thin, transparent skins show the super- 
ficial hyperemic condition much more plainly than others. 

The swelling is the effect of the diapedesis, or escape of the 
elements of the blood through the walls of the vessels, because of 
their changed condition under the irritation manifested through the 
vaso-motor nerves. The tissues are thus infiltrated and distended. 
The amount of this dilatation or expansion will depend upon the 
nature of the tissue in which it takes place, and upon the character 
of the functional disturbance. 

The pain is the effect produced upon the terminal nervous fila- 
ments by the deranged condition, and the pressure of the exudate. 
Sometimes this will be of a throbbing character, due to the pres- 
sure exerted by the arterioles at each heart contraction, or systole, 
upon the already irritated and sensitive terminal nerve filaments. 
Boring pains are usually connected with inflammations of bone 
tissue. Lancinating pains ordinarily accompany acute swellings, 
and are indicative of a determining abscess. Soreness is due to the 
formation of an abscess cavity in a very sensitive tissue or organ. 
That of a boil, which is an instance of suppurative inflammation, is 
proverbial. 



36 ORAL PATHOLOGY AND PRACTICE. 

The general fever is the result of the sympathy of other organs 
with that which is directly affected. It is the office of the nervous 
system to preserve the equilibrium of the various functions of the 
body. When this is disturbed by an aberration existing in any 
organ, all the others suffer to a greater or less degree, and thus is 
produced a general feeling of malaise or discomfort. 

The causes which excite an inflammatory condition are divided 
into predisposing and exciting. 

Predisposing causes are special conditions of the body which 
render the organs or tissues more liable to take on the pathological 
conditions. In the presence of predisposing causes, comparatively 
slight irritation may result in serious disturbances. A state of 
atony, or asthenia, or general debility, reduces the resistive force of 
the tissues and promotes the invasion of disease. Anemia is 
another predisposing cause, the poverty of the blood, or the lack of 
certain of its elements, seriously interfering with that nutrition 
which must maintain the general tone. 

The exciting causes of inflammation are very many, and include 
whatever may produce shock, such as cold, heat, traumatism or 
injuries, etc. A common cold is an inflammation induced by sub- 
jecting one part of the body to a sudden diminution of its tem- 
perature, and thus disturbing the general nervous equilibrium or 
tone. Many chemical substances are nervous irritants, either 
through direct or reflex action. Poisons act in this way, and these 
include the stings of bees, the bites of many insects, and the pecu- 
liar effect of certain vegetables, such as poison ivy and oak. 

Many of the pathogenic micro-organisms induce a state of inflam- 
mation through their growth in the system. All lesions, wounds, and 
injuries give a shock that is more or less profound, and thus bring 
about inflammatory conditions. 

A cachectic state, or dyscrasia, is one either of disturbed gen- 
eral nutrition or of local degeneration, that makes the organs 
liable to inflammation, as in gout, calculus, etc. 

It has already been affirmed that a nervous shock that affects 
the vasomotor system may so change the condition of the blood- 
vessels as to permit the escape of a portion of their contents. John 
Hunter recognized the intimate connection of the blood current 
with inflammatory processes, and declared that hyperemia and con- 
gestion were their initiative stages. Less than thirty years ago, 



FURTHER DEGENERATIVE CHANGES. 37 

Cohnheim published the results of a series of observations that 
gave the world a new insight into the pathological changes that ac- 
company this disturbed condition, especially in the earlier modifica- 
tions. Other pathologists have carried the explorations further, 
and some of them have dissented from a part of the conclusions of 
Cohnheim, but his general deductions are accepted as correct by 
most pathologists. 



CHAPTER VIII. 

FURTHER DEGENERATIVE CHANGES. 

If the mesentery of a frog is exposed to the air and placed 
under a microscope, it will be seen that the flow of blood in the 
capillaries is greatly augmented. They are distended, and many 
that had been invisible are by this dilatation brought into view. 
The leucocytes, or white blood corpuscles, are gradually increased 
in number. Regions in which there normally appears only an 
occasional one, soon become thronged with them. The increased 
velocity of the current lasts but a short time, when the flow begins 
to be retarded, and is soon slower than the normal, the distention 
still remaining. A partial stagnation succeeds, and the white 
corpuscles begin to accumulate in the small veins and arteries, and 
show a tendency to cling to the walls. They are swept back into 
the lessening current, but soon find another point of attraction, and 
finally remain attached to the lining surface. They soon become 
so enormously increased that the inner surface of the vessels is 
completely covered with them. In the capillaries and arteries the 
white corpuscles are mingled with the red, and do not accumulate 
in such great numbers, but in small veins they seem to have become 
separated from the red and to cling in greater numbers. 

Soon they begin to alter their appearance, and to exercise 
their peculiar ameboid, or spontaneous change-of-form movements. 
(See Fig. n.) The vessel wall remaining distended, after a little 
time there is observed upon its external surface a minute protuber- 
ance, which momentarily increases, the cell opposite upon the 
internal wall correspondingly diminishing, until it is seen that the 
whole of the jelly-like protoplasmic leucocyte has penetrated the 



38 



ORAL PATHOLOGY AND PRACTICE. 



walls and been extruded upon the periphery. Coincidental with 
the changed condition of the vessel walls, other of the contents have 
passed through and invaded the surrounding tissues. The leuco- 
cytes have been considered as the active agents of repair, themselves 
forming the initial or germinating point in the organization of the 
plastic exudate into tissue. This hypothesis seems most consistent 
with known facts, and offers a ready explanation of some phe- 
nomena not otherwise comprehensible. 

It is but proper to say that this theory is not accepted by some 
histologists and embryologists, who consider the leucocytes but as 
scavengers for the removal of offensive matter. 





Leucocytes, showing Ameboid Movements. 



b, c, d, Pseudopodia. 



e, Constriction when passing through the coats of a bloodvessel. 
(Very much enlarged.) 



That the leucocytes have a digestive power, appropriating 
bacteria, has been shown by a number of observers. They may 
also be useful in consuming portions of broken-down tissue, and 
hence assist in the absorption of blood-clots, exudations, etc. But 
that this is their sole office does not seem congruous or compatible 
with demonstrated truths, and it is not accepted in this connection. 

The number of leucocytes is notably increased during inflam- 
mation. They may be seen to gather in great numbers in the 
smaller vessels, and they migrate in profusion into the surrounding 
tissues. Their origin is yet in dispute. It was formerly held that 
their multiplication was due to increased cell proliferation or for- 
mation under the stimulus of the inflammatory process. But Von 
Recklinghausen found in connective tissue two kinds of cells, 
which he called the fixed and the wandering. The former he says 
are stationary among the fibers of the intercellular substance, and 



FURTHER DEGENERATIVE CHANGES. 39 

are round, or spindle-shaped. In addition to these he observed 
other cells, in all respects resembling the leucocytes, which take on 
spontaneous changes of shape by means of the extension of a 
portion of their jelly-like substance (pseudopodia — false feet), such 
as are characteristic of the ameba, and hence called ameboid move- 
ments. By means of these mutations they constantly changed 
their location, passing through the meshes of the lymph canals, 
entering from the blood and escaping through the lymphatics, thus 
keeping up a constant circulation. In normal tissues they were 
few in number, but in the presence of irritation or inflammation 
they were inordinately multiplied. ' 

This is the generally accepted theory of to-day. The wander- 
ing cells of Von Recklinghausen, or the white blood corpuscles, 
or leucocytes, which even in entire health are escaping through the 
walls of the bloodvessels in small numbers, by means of their 
ameboid movements may traverse the tissues through the lymph 
channels until they are finally extruded. Their probable generation 
is in the lymph glands or nodes, the spleen, etc., and in inflammatory 
conditions they are enormously increased, and are carried by the 
blood to the disturbed territory, whence they readily pass into the 
tissues through the changed condition of the vessel walls. Their 
multiplication in an inflamed tissue is in proportion to the violence 
of the disturbance. 

Corresponding to this increase in the number of the white 
blood corpuscles in the tissues is the extravasation from the blood- 
vessels of the fluid portions, or the blood plasma. The fibrinogen 
which this contains, coming in contact with the paraglobulin and 
ferment of the leucocytes under their changed condition, fibrin is 
formed and the lymph is coagulated or fixed in the tissues. The 
product thus formed, with the emigrated blood cells, composes that 
which is known as the "plastic exudate" (plastic or organizable 
lymph, fibrinous lymph), and it is the progressive or degenerative 
changes in this substance that constitute the further phenomena of 
inflammation. 

The plastic exudate once having been formed in the tissues, it 
may assume such a complete fibrination, such an entire conversion 
into a dense compact fibrin, as to produce that which is called an 
induration. This at times assumes to the fingers almost the hard- 
ness of bone. In inflammation of the tissues about the jaws it is 



40 ORAL PATHOLOGY AND PRACTICE. 

not infrequently mistaken by the novice for bone, and a wrong 
diagnosis is accordingly made. It may be immovable, without 
special sensation or pain, and apparently closely attached to the 
osseous tissue. In this form the plastic exudate is persistent and 
indolent in its character, and does not readily degenerate nor 
assume a progressive aspect. It may disappear under the slow 
process of gradual resorption, or it may eventually break down. 



CHAPTER IX. 

THE PRODUCTS OF INFLAMMATION. 

The methods by which the plastic exudate, or the coagulable or 
fibrous lymph, and the remaining products of inflammatory condi- 
tions may be disposed of, are by (1) Resolution, (2) Building up, 
(3) Tearing down. 

Resolution means the taking up of the products by the absorbents, 
and their disposition through the lymphatic system. There is a 
cessation of irritation, the bloodvessels return to their normal 
condition, exudation ceases, and there is a gradual return to a 
true physiological state, as there is when hyperemia alone exists 
and the disturbance does not extend to the point of active inflam- 
mation. 

Building up of tissue means that the plastic exudate has been 
by regular progressive changes organized into tissue of an embryonic 
character. The methods of this metamorphosis are by first, second, 
and third intention. 

First Intention. — This implies a regular progression from the 
commencement, zvithout any degenerative changes zvhatever. A r o 
pus is formed, nor is there infection by micro-organisms. The 
term "healing by first intention" is usually applied to wounds, 
either traumatic or surgical, especially to those of an incised 
character. If the gaping produced by the elasticity of the tissues 
is closed, and the severed parts brought into nice coaptation, 
either by stitches, adhesive plaster, or finger manipulation, the 
fibrin that is formed by the plastic exudate agglutinates or cements 
them together, and union without any violent or disruptive 
inflammation may ensue. This can only be secured by thoroughly 



THE PRODUCTS OF INFLAMMATION. 41 

aseptic conditions, and it is this at which all surgeons aim in their 
treatment after operations. 

Granulation, or Second Intention. — This is the building up of 
the tissue, or the organization of the exudate by means of papillcu, 
or gram-like growths, that spring up from the base of healing 
wounds. It is a progression cell by cell, instead of organization 



Fig 




Granulating Tissue, showing the Capillary Loops. (After Rindfleisch.) 

a, Dead leucocytes, b, Granulating tissue, c, Commencing: metamorphosis of granulations 

into a fibrous structure. 

more in mass. Capillary loops are formed in the extravasated 
plasma, which as it is poured out will be found shielded by a kind 
of transparent glistening film, that protects it until the lost tissue 
has been restored and the skin shall have been formed over it. 
This new growth is known as granulation tissue, and is always 
of a cicatricial or elementary character. The new formation is 
primarily of the connective tissue variety, and is subsequently 
modified into that of which it forms a part. (See Fig. 12.) 



42 ORAL PATHOLOGY AND PRACTICE. 

The organization of the tissue, when it proceeds without any- 
degenerative processes, may be clinically studied in the socket 
from which a tooth has been extracted. The cavity will at first 
be found filled with coagulated blood, which effectually seals the 
mouths of the ruptured vessels. Within a very few days at the 
most, this will have been sloughed away or materially modified, and 
the socket of the root will be found occupied by a kind of trans- 
lucent, jelly-like substance, which is very easily wiped away with a 
pledget of cotton. If it is left undisturbed a short time longer, it 
assumes a firmer consistence and becomes opaque and of a whitish 
color. This is the plastic exudate that has been effused. It now 
cuts like gelatin, and has the same general appearance. Another 
day, and if it be divided with an excavator or the point of a sharp 
bistoury, a minute drop of blood will ooze out. This indicates 
the formation of blood channels within the mass. There is no 
continuance of blood flow, for circulation has not yet been estab- 
lished, but minute sinuses have been formed, and they are filled 
with sanguinary fluid. In yet another day or two these will have 
become connected with the blood channels of the surrounding 
tissues, and a form of circulation will have been established. The 
exudate is now firmer, and cuts like new, partially formed carti- 
laginous tissue. The mucous membrane and epithelia form over 
it, and it assumes the appearance of the surrounding gums. Then 
commences the process of calcification, and soon the knife feels 
the grating of formative bone. Calcification proceeds until the 
cavity is completely filled with well-organized bone tissue. This 
peculiar form of healing by first intention will not be observed 
except in cavities that are well protected from external violence. 

If this kind of formative tissue in its early periods of develop- 
ment is examined under a microscope, it will be found filled with 
small round cells, which gradually assume a spindle form, and 
the deepest layer will be found composed of bundles of them. 
This is a part of the process of the formation of embryonal tissue, 
which gradually is developed into that of a more perfect type. 
The cicatrix is connective tissue that has contracted in the course 
of its formation, and which thus tends to draw together the edges 
of a wound, but which may be so excessive as seriously to inter- 
fere with function, as is the case in extensive burns. The surgeon 
accomplishes this coaptation of the borders of wounds by means 
of sutures. 



THE PRODUCTS OF INFLAMMATION. 43 

Third Intention. — This is the term applied to the process of 
healing zvhen two granulating superficies come or are brought 
into coaptation. It does not essentially differ from second inten- 
tion, which, indeed, must be precedent to the union of the granulat- 
ing surfaces. 

When by means of a continuance of the irritation the inflam- 
matory process is exacerbated, or when new sources of irritation 
are introduced and infection succeeds, the healing process is inter- 
fered with, and the plastic exudate, instead of being organized into 
tissue, loses its integrity and is broken down, involving the invest- 
ing tissue. This may be by (1) Suppuration, (2) Gangrene, (3) 
Necrosis. 

Suppuration, or the formation of pus, is molecular degenera- 
tion through septic infection. The exudate, from continued irrita- 
tion or from a lack of nutrition, loses its organizing power, becomes 
infected by pyogenic micro-organisms, degenerates, and forms pus. 
The leucocytes, or white blood corpuscles that have migrated to 
the inflamed territory, die and become the characteristic pus 
corpuscle. The plasma melts down and is mingled with the 
extravasated serum of the blood. The tissue in the immediate 
neighborhood is infected, degenerates and breaks down, and a pus 
cavity is thus formed. 

Pus, then, is composed of (a) the pus corpuscles or dead leuco- 
cytes, (b) the melted down plasma and exuded serum from the blood, 
and (c) the necrotic or decomposed tissue into which it has been 
infiltrated. It is essentially a foreign substance, and Nature puts 
forth her utmost efforts to expel it from the system. The pressure is 
considerable, and the tissue in the line of least resistance yields and 
becomes disorganized and decomposed, thus extending the pus 
cavity, usually toward the periphery, or some natural cavity of 
the body. This continues until it is discharged upon the surface 
and an abscess is formed. The determination of this destructive 
process toward the place of exit is called the "pointing" of the 
abscess. 

If the irritation has now ceased, as in the case of the extru- 
sion or removal of some foreign substance that was in the tissues, 
the process of healing commences, and may proceed by granula- 
tion until the lesion has been completely restored. If the irritant 



44 ORAL PATHOLOGY AND PRACTICE. 

is not carried away by the first suppuration the process will be 
repeated. In a discharging alveolar abscess arising from irritation 
and infection of the pericementum of a dead tooth, the plastic 
exudate will be effused about the point of irritation, only to be 
infected in its turn, and to break down with new formation of pus. 
At first these pointings will be periodical. They may be precipi- 
tated by any general inflammatory condition, and follow upon the 
so-called taking of a cold. After a time the condition becomes 
chronic. There is a steady effusion of the exudate, and it is as 
regularly infected and broken down, and thus an almost continuous 
discharge of pus from the sinus formed is the result. 

Pus was formerly classed as laudable or healthy, serous, 
sanious, ichorous, etc. We now know that the thick, creamy, 
opaque, yellowish discharge, which was formerly denominated 
laudable pus, is the uncontaminated, undecomposed discharge from 
a healthy granulating surface, or from one in the process of normal 
healing. 

Ichorous pics is the thin and acrid ejection from an ulcerative 
surface, or is that which has passed through a second degenerative 
process. It may be excoriating and cause an abrasion of the sur- 
rounding tissues if they are not protected from its .influence. 

Sanious pus is that which is mixed with blood, and which partakes 
of the nature of both. It is usually an indication of a destructive 
action, and of the cellular sloughing that accompanies the breaking 
down of tissue. It may be ichorous in its character. 

Serous pus is that which is mixed with scrum from the blood. 
It differs from sanious pus, in that it is more simple in its nature, 
and is not indicative of secondary putrefactive changes. 

Muco-pus is that which is mixed with the secretions of the mucous 
glands. This is probably but an accidental complication, and the 
character of the pus is not thereby materially changed. It does not 
imply that there has been any secondary infection with destructive 
organisms, or any putrefactive degenerations. 

Gangrene is also known as mortification, and when sloughing 
takes place, as sphacelus. It is the cessation of all nutrition in a 
territory more or less considerable and circumscribed, with a conse- 
quent loss of function and death in mass. Its origin may be in a 
traumatism or wound, in a local cause like thrombus or embolism, 
in continued pressure either external or internal, in the too free 



THE PRODUCTS OF INFLAMMATION. 45 

use of certain drugs, such as ergot, phosphorus, mercury, or 
carbolic acid, and finally in constitutional causes, such as diabetes 
or anemia. It is usually divided into moist and dry, or senile, 
gangrene. When the degenerative changes which succeed loss 
of nutrition in a part have commenced, there may be an infection 
with certain bacteria of decomposition, and the whole territory 
become highly septic. The tissue is in a putrefactive state, and 
auto- or self-inoculation in other tissues may be the result. This is 
common, or moist gangrene. 

In addition to these septic conditions of gangrenous degen- 
erations, the disease may be the direct result of infection. There 
are special types, due to the activity of micro-organisms, that have 
long been distinguished as phlegmonous erysipelas, malignant 
edema, hospital gangrene, noma, etc. Hospital gangrene is now 
almost unknown, its disappearance as a separate affection being 
due to our increased knowledge of septic conditions, and to anti- 
septic precautions and treatment. 

Dry or senile gangrene presents a marked difference in its 
objective appearance to that of the moist type. As its name indi- 
cates, it occurs usually in old people, being seldom found in those 
under fifty years of age. It is usually caused by arterial disease 
or degeneration, through which the circulation in a part is cut 
off. The tissue being deprived of blood, the moisture is lost by 
evaporation, and there is a consequent shrinking and wrinkling 
of the tissues, which produces that peculiar appearance called 
mummification. If from the outset putrefaction is prevented, the 
type of gangrene is always dry. 

This affection may usually be readily diagnosed. The pecu- 
liar appearance of the tissues, with the odor of putrefaction, in 
moist gangrene, and the coldness, dryness, and pallor of dry 
gangrene, seldom leave the surgeon in doubt as to the nature of 
the affection. 

Necrosis, which in its general signification means the death of a 
part, may be properly used to include gangrene. In its surgical 
employment the term is now restricted to death of the hard or bony 
tissue. It is the analogue of gangrene in soft tissues, and it has 
the same general etiological origin. It is the stoppage of the 
nutritive currents, with the consequent death of the part. From 
the nature of the tissue in which it exists, its progress is nat- 



46 ORAL PATHOLOGY AND PRACTICE. 

urally slower than is that of gangrene, but the tendency is the 
same, and it should end in the sloughing away of the dead part 
from the living. When such a necrosed portion of a bone is 
thus separated, it is called the sequestrum, while the result of a 
successful effort of nature to build up new bone in its place is called 
the involucrum. Of all the bones of the body the inferior maxillary 
is most apt to take upon itself necrosed conditions. This is partly 
because it is more subject to accidents than most bones, but chiefly 
because from its peculiar connection with the rest of the body, its 
great mobility and the constant and violent uses which it is made 
to subserve, nutrition is the more readily interfered with. About 
three cases of necrosis of the lower jaw occur to one of the upper. 

It will be seen, from a retrospective view of the preceding 
statements of the condition called inflammation, that it is, as was 
affirmed at the outset, the initial point of very many changes in 
the body, of a physiological as well as of a pathological nature. 
It commences with simple hyperemia, and ends with the final 
disposal of the plastic exudate by either progressive or retro- 
gressive metamorphosis. It is the result of an irritant, which 
produces a more or less profound impression upon the tissues 
through the nervous shock. The vaso-motor system is thereby so 
disturbed as to modify the conditions of the bloodvessels in the 
neighborhood of any lesion, and to permit the passage into the 
tissues of their contents, through diapedesis. This extravasated 
matter is the plastic exudate that is either organized or disorgan- 
ized, and it is the result of the earlier stages of the inflammatory 
process. 

The termination of inflammation, then, is either in the build- 
ing up of the plastic exudate into new tissue, by first intention or 
by granulation, or in its degeneration and tearing down by suppura- 
tion, gangrene, or necrosis. The final result depends upon the 
degree of the lesion or injury, upon external sanitary or unsanitary 
surroundings, upon constitutional tonic or atonic conditions, and 
upon the ability to maintain the circulation practically unimpaired. 



GENERAL TREATMENT OF INFLAMMATION. 47 

CHAPTER X. 
GENERAL TREATMENT OF INFLAMMATION. 

The treatment of inflammatory states will necessarily be 
largely general in its character. The various remedies to be 
employed may be classified as follows: 

For the heat — Reduce the temperature by refrigerants. 

For the swelling — Use compression : apply bandages. 

For the hyperemia — Use depletion : leeches, cupping, etc. 

To produce metastasis — Counter-irritants, blisters, etc. 

To relieve circulation — Cathartics, diaphoretics, diuretics. 

To equalize the circulation — Hot pediluvia (foot-baths). 

For the fever — Febrifuges, antiphlogistics. 

For the pain — Sedatives, anodynes, local anesthetics. 

To promote suppuration — Warmth, moisture, poultices. 

The first remedial measure to be employed will of course be 
the removal of the cause of the irritation, provided this can be 
definitely ascertained. The next will be to give rest to the parts. 
The latter is best secured by immobility and entire repose. All 
use of the affected organ should cease, and it should be placed 
in the easiest position possible. Saline cathartics may be adminis- 
tered, with the view of relieving the tension of the bloodvessels 
by a depletion of their watery contents. Diuretics are useful for 
the same reason. If a laxative only is desired, Seidlitz powders 
may be prescribed, or mild doses of castor oil. For a saline 
cathartic, Epsom or Rochelle salts (magnesium sulphate, sodium 
tartrate), or cream of tartar (potassium bitartrate), may be 
employed. But still more efficacious are diaphoretic remedies, 
because they not only remove the water of the blood and tissues 
but act as refrigerants, through evaporation from the surface. 
They also tend to depuration by opening the pores of that great 
eliminative organ, the skin. Dover's powder, or some form of 
alcohol, with warmth and diluent drinks, may be used. In general 
forms of inflammation, febrifuges, such as potassium chlorate, 
quinine, antipyrine, and antifebrine, should be administered, and the 
general hygiene should be carefully looked to. If there is general 
irritation, sedatives, either arterial or nervous, as may be indicated, 
should be given. 



48 ORAL PATHOLOGY AND PRACTICE. 

If the inflammation shall have proceeded to the point of 
effusion of its products, early efforts are usually directed toward 
bringing about resolution, or absorption of the lymph. 

Local cupping or bleeding may be useful, although the best 
means for securing local depletion will usually be by the applica- 
tion of leeches. These agents, which have of late been almost 
entirely abandoned, will often prove of greatest efficacy. In addi- 
tion to the general remedies recommended, counter-irritants may 
be employed. These induce a change in the location of the 
inflammation by metastasis, or the production of a new point of 
irritation, with the consequent transference of the seat of diseased 
action. 

Park recommends, in forms of phlegmonous infiltration, the 
application of an ointment composed of resorcin 5, ichthyol 10, 
mercurial ointment 3, and lanolin 50 parts, as a sorbefacient and 
antiseptic preparation. This in connection with moist heat may 
even secure the actual resorption of pus. 

If there is local swelling, it may sometimes be controlled 
by bandaging, which prevents further effusion and promotes the 
absorption of that which has already taken place. It is not, 
however, usually convenient to apply a bandage or exert much 
pressure upon any of the oral tissues. 

If there is considerable local heat, it may be controlled by 
the application of ice, or by the ether or alcoholic spray. 

If neither resolution nor building up of tissue seems possible 
or probable, efforts should be directed toward the promotion of 
suppuration, thus relieving the tissues of the products of the 
inflammatory process. It is here that the oral physician or sur- 
geon will have an opportunity for the exercise of his best judg- 
ment, and all his experience will be needed in making his prog- 
nosis, to determine the exact point at which the treatment should 
be changed. To ascertain when the degenerative process has 
begun requires the nicest perception and discernment. In 
inflammation of the dental pulp, for instance, to know when it 
is no longer wise to attempt to preserve its vitality, and when 
devitalization and extirpation are advisable in view of positive 
degenerative changes that are imminent, requires a thorough 
knowledge, not only of the whole inflammatory process, but of 
the symptomatography of all the lesions and complications as well. 



GENERAL TREATMENT OF INFLAMMATION. 49 

The breaking down of tissue having already commenced, or 
being plainly inevitable, suppuration should be hastened, that the 
more destructive processes of gangrene and necrosis may not 
supersede it. Poultices should at once be employed in the direc- 
tion in which it is desired that the abscess shall break. This 
promotes suppuration by extending such favorable conditions as 
are afforded by a maintenance of the temperature, the continued 
presence of moisture for the softening of the tissues, and the dila- 
tation of the vessels. Any poultice that will secure this will suffice, 
although if it is of a fermentative substance, that process will assist 
in the weakening of the superincumbent tissues. 

It is not convenient to use for oral application the poultices 
commonly employed in general medicine. A freshly cut fig or 
a split raisin may often be applied when no other can, and they 
act very effectually. They should usually be softened and warmed 
by dipping in hot water. They are pleasant to use in the mouth, 
and when one piece becomes too much softened another is readily 
substituted. They will usually be held in place by the facial 
muscles. 

There are certain general remedies that promote suppuration 
under definite conditions, but they are little adapted to oral prac- 
tice. In the treatment of inflammation the aim should always be, 
after diapedesis has taken place, to relieve the tissues of the exu- 
date material, and to promote healing when there has been any 
traumatic wound or lesion. 

Whenever pus is present it must be promptly evacuated. 
It is always irritative, always degenerative in its influence. 
There is no precept in practice that is so imperative as the one 
which instructs the practitioner at once to get rid of pus. There 
is no surgical risk that one is not justified in taking if this product 
can be eliminated in no other way. Sometimes a mere puncture will 
evacuate it, at other times a serious operation is demanded; but, 
whether simple or complicated the means of elimination, it must 
not be permitted to remain. Some judgment may be required in 
securing perfect drainage if an opening is made, and this demands 
that the artificial sinus shall be at the lowest, most dependent point 
when the body is in its natural position. Drainage tubes may be 
demanded; or gauze, catgut strands, or other media may be used 
to keep the opening patulous. These may be retained in position 
by strips of adhesive plaster. 

5 



50 ORAL PATHOLOGY AND PRACTICE. 

After evacuation the pus cavity should be cleansed and disin- 
fected with hydrogen dioxide, pyrozone, or some other effective 
antiseptic or disinfectant solution. The utmost care should after- 
ward be exerted to keep the cavity clean and aseptic, if proper heal- 
ing after the discharge of the broken-down infiltrate is to be 
secured. 



CHAPTER XL 
DISEASES OF THE GUMS. 



The gums are largely made up of fibrous tissue covered by 
mucous membrane. In their normal condition they are of a deli- 
cate pink color, and are dense and hard. They invest the teeth 
closely, and are adherent at their cervical portion. They are not 
especially sensitive, and in the absence of the teeth most kinds of 
food may be crushed upon them without great discomfort. Any 
departure from this general appearance or state is a pathological 
condition that demands attention from the dentist or oral physi- 
cian. Local irritations, inflammations and hypertrophies, or hyper- 
plastic conditions of the gum tissues are, however, too seldom 
recognized, or if noticed are not accorded proper treatment. That 
which should form a considerable proportion of the practice of 
every dentist is sadly neglected. 

Especially has this been the case in the past. Formerly the 
college terms were so short that it was absolutely impossible to 
give adequate instruction in very many pathological conditions. 
Of late the curriculum has been materially broadened, and students 
have impressed upon them the overwhelming importance of prophy- 
lactic treatment and the early employment of remedial measures for 
the cure of oral disorders, before they shall have wrought irrepar- 
able mischief. 

Inflamed, irritable, turgid gingivae, loosened from their 
attachment to the teeth so that the point of an explorer can pene- 
trate some distance beneath their free margins without resistance, 
with degenerated, atonic, congested bloodvessels that discharge 
their contents at the least irritation, are even now so common as to 
excite little comment, and the patient is dismissed without the 



DISEASES OF THE GUMS. 5 1 

proper professional advice or remedial attention. (See Fig. 13.) 
These same unfaithful practitioners perhaps bewail the multiplica- 
tion of dentists, and insist that our schools should limit the launch- 
ing of new graduates upon an already crowded profession, because 
there is not enough of practice for those already in, while them- 
selves neglecting a large proportion of the field that should be 
covered. Properly to care for the disregarded conditions of the 
mouths of the people of this country would far more than employ 
the time of all the dentists now in practice. The proper remedy for 
a stream that overflows its banks is to widen and deepen its channel, 
instead of attempting to dry up its waters, and there are unoccupied 
fields within the province of dentistry not only as yet uncultivated 
but almost unexplored. 

Local irritation is the cause of most of the inflammations and 
hypertrophies of the gums that are so commonly met with. Usually 

Fig. 13. 




Gingival Hypertrophy and Turgescence, the Result of Neglect. 

this is due to lack of care on the part of the patient. Foreign mat- 
ter is deposited at the cervical portions of the teeth, and this by its 
excitant action stimulates the tissues to abnormal activity. The 
consequence is an overgrowth, an hypertrophy or hyperplasia of 
tissue. This may be confined to a single tooth, or it may be more 
widely diffused and involve nearly or quite the whole of the denti- 
tion. The tumefaction will be especially pronounced in the gum 
covering the septum between the teeth, where the irritation is 
greatest. If there are carious cavities, not infrequently they will be 
completely filled with hyperplastic tissue, connected with the rest 
by a slender pedicle. The margins of the gums will be thick, 
everted, and of a deep red color, almost approaching a purple. 
There may be a breaking down of the tissue with pus formation, 
entirely distinct from that condition called pyorrhea. The mucous 
follicles of the gums are in a degenerative state, and their secretion 



52 ORAL PATHOLOGY AND PRACTICE. 

no longer properly lubricates the tissues, but adds to the disturb- 
ance by its perverted character. 

These conditions arise as the effect of lack of care, local irri- 
tation due to the presence of foreign substances, rough projecting 
fillings, or deposits about the necks of the teeth. Diagnosis is not 
difficult, for the very existence of the disturbance indicates the 
presence of exciting agents. The first curative measures to be 
adopted obviously is the removal of any local deposits or foreign 
substances. Nor is it sufficient to do this superficially. Wherever 
there is any undue amount of tissue or tumefaction, beneath it, 
perhaps at the very edge of the alveolar walls, will be found some- 
thing foreign. It is absolutely essential that the instrument used 
should penetrate to the point of attachment beneath the inflamed 
tissue, and to this end one that has a chisel edge, adapted to a 
pushing motion, will be most effectual, for anything thicker will 
not reach to the very extremity. It should not be forgotten that 
the most mischievous irritant matter is that which lies deepest, 
and nearest the point of actual attachment of the pericementum to 
the tooth. 

Minute spicules of calcific matter are those which cause the 
greatest disturbance. Whether these have their origin in the fluids 
of the mouth or of the circulatory system, whether they are salivary 
or sanguinary, local or constitutional, their operative treatment is 
the same. That such deposits of hard, sharp, segregated granules 
beneath the gums differ from the ordinary tartar or salivary calculus 
that is precipitated upon the supra-gingival portions of the teeth 
must be patent to everyone, but whether this divergence is due to 
its derivation, or merely to the manner and place of its deposit, we 
need not now inquire. Certain it is that its removal is more diffi- 
cult than that of ordinary salivary calculus. It perhaps will not be 
detected without the exercise of considerable care, for it sometimes 
exists in minute granules that would be invisible even if not covered 
by the inflamed gum. 

A solution of trichloracetic acid, of from twenty to fifty per 
cent, will greatly aid in the removal of these deposits. It may be 
carried on the edge of a sharp, wedge-shaped piece of orange wood 
that has been dipped in the solution, or a small rope of cotton may 
be saturated and with an excavator carefully carried up to the very 
point of attachment of gum and tooth, and there allowed to remain 



DISEASES OF THE GUMS. 53 

for a few moments. While the acid does not remove the deposits 
by dissolving them, it will loosen their attachment to the teeth, 
and soften them enough to facilitate their removal with the scaler. 
At the same time the remedy acts as a slight cauterant, inducing a 
slough of the superficial parts of .the degenerative tissue, and reduc- 
tion of the inflammatory condition by its astringent and alterative 
action upon the distended, congested capillaries. A solution of 
lactic acid has been highly recommended for the same purpose. 
The patient should be directed to use frequent massage of the 
gums with the ball of the finger, and the persistent use of a soft 
tooth-brush should be insisted upon. The mouth should be gargled 
and the gums washed with a solution of ten grains of chlorate of 
potash to the ounce of water, and if necessary a solution of chloride 
of zinc may be prescribed for oral use. If there is a great deal of 
bleeding, tannic acid may be rubbed upon the gums with the finger. 
If, as is probable, an antiseptic wash is needed, a solution of boro- 
glycerol in water, one part to ten, may be used as a wash or with 
the brush. It will not usually be wise to attempt the removal of the 
deposits from all the teeth at one time, if many are affected. 

The medicinal treatment needs repeating at intervals of a few 
days until the condition is changed, and it is well at each of the 
visits to explore still further for irritating, substances. An indica- 
tion of their existence and their locality will be found in the local 
persistence of the inflammation. Any red, irritable point of hyper- 
frophied gum will usually be found to cover the cause of irritation. 

Of the inflammations arising from loose or ragged teeth it is 
unnecessary to speak. The removal of the source of irritation 
will be sufficient. The gums beneath ill-fitting plates frequently 
become tumefied, and sometimes sloughing ensues. This is 
especially the case with rubber plates, not because they generate 
any heat, but because they are non-conductors and the tissue 
beneath them is not subjected to the same variations of tempera- 
ture as the other and surrounding tissues. The condition may 
sometimes be found beneath metal plates that are not adapted to 
the mouth, if they are worn continuously, but there is not the 
same degenerative lack of tone in the bloodvessels that is found 
beneath rubber dentures. The congestion is usually less intense, 
and sloughing is more infrequent. The cure for this condition will 
be found in the construction of a proper denture, and its inter- 



54 ORAL PATHOLOGY AND PRACTICE. 

rupted use. No artificial plate should be allowed to remain in the 
mouth over night. The tissues should be given that opportunity 
for rest and the recovery of their normal tone. 



CHAPTER XII. 
STOMATITIS. 



The word is derived from the Greek "stoma," a mouth, and the 
termination "itis," inflammation, so that it implies an inflamma- 
tory condition of the tissues of the mouth. The term is a very 
broad one, and may be made to cover very diverse conditions. Its 
application, however, is usually restricted to the mucous mem- 
brane and the soft tissues in immediate relation with it. It is very 
common in infants, among the lower classes of foreigners espe- 
cially, arid is usually due to bad hygiene or unsanitary conditions. 
Especially is this the case with those that are artificially fed instead 
of being nursed by the mother. Either the food is of an improper 
character, or the nursing-bottle is not often enough scalded or 
boiled out to prevent the growth of fermentative organisms, and 
the milk used is thus infected. The rubber nipple and tube are 
often the source of irritation to the oral tissues. The rubber under 
the influence of light and heat rapidly commences decomposition, 
and. thus becomes the means of poisoning the mouth; or it may 
harbor destructive fungi, and these are especially irritating to the 
mucous membrane. 

Follicular Stomatitis, the simplest form, is an inflammation of the 
mouths of the mucous follicles. It is either accompanied by or will 
bring about degenerative changes of the mucosa itself, and this 
may add materially to the irritation. Perhaps but a portion of the 
surface may be affected, and the membrane presents a punctate 
appearance — flecked over with red points. With the increase of 
the inflammatory condition more of the follicles are involved, until 
the patches become confluent, and the whole surface is tumid and 
turgid. In this condition the tissues of the mouth look hot, dry, 
and red. The mouth becomes sensitive, and the child shrinks 
from its examination. There will, in the earlier stages, be an 



STOMATITIS. 55 

excessive slavering, or flow of watery saliva. There will be more 
or less of febrile disturbance, and the bowels will probably be 
irregular, a constipated condition predominating. During a later 
stage the secretions of the follicles become yet more depraved 
and no longer give the normal lubrication to the parts. The de- 
generation spreads to the connective tissue, the mouth becomes 
dry and parched, the bloodvessels are congested and active nutri- 
tion is interrupted, the congestion reaches the point of stasis, or 
stoppage of the circulation, and sloughing commences. 

Acute Stomatitis may be induced by improper feeding, aside 
from unsanitary conditions. The infant that is fed with a food 
that it cannot digest will be poorly nourished, and all kinds of 
degenerations may be established. The irritative condition of the 
digestive tract may produce diarrhea and gastric disturbances 
which by mere continuity of tissue may extend to the oral mucous 
membrane, and an ulcerative stomatitis may be established as the 
result of the atonic, innutritive state, and the spread of the inflam- 
mation from the irritated digestive tract. 

Ulcerative Stomatitis is merely an advanced stage of the first 
condition. The mucous follicles become so degenerated that their 
functions quite cease, and cracks and fissures open in the unlubri- 
cated tissues. All the preceding symptoms are aggravated. The 
child cannot without great difficulty take its food, and what is 
ingested affords little nutriment, because of the gastric disturb- 
ances that are always present. There is a constant swallowing of 
offensive matter from the mouth, with a wasting diarrhea or dysen- 
tery. 

About this time the submucous tissue will perhaps become 
thickened and indurated in spots. Sometimes there will be ptyal- 
ism, with a great flow of watery saliva succeeding the dried condi- 
tion of the oral cavity. The submaxillary gland may become ten- 
der and tumid. Small vesicles may appear in the mouth, seem- 
ingly filled with a watery serum. These burst and form an ulcer, 
with a dirty-white slough. The child becomes greatly emaciated, 
and there is excessive swelling of the oral tissues. The breath 
becomes very offensive, and the ulcers show a considerable slough- 
ing. Unless speedy relief is obtained, the child will soon succumb 
through lack of nutrition, as well as to the infectious products of 
the septic condition. 



56 ORAL PATHOLOGY AND PRACTICE. 

Aphthous Stomatitis is a form that may attack people of almost 
any age, and is characterized by some special appearances. Small 
round or oval ulcers appear upon the reddened mucous membrane 
of the lips, cheeks, tongue, or gums. They are from one to three 
lines in diameter, very little depressed, with a yellowish or white 
floor, and a red, narrow, perhaps slightly indurated, border. 
Sometimes two or more of them become confluent, thus forming 
an irregular, large ulcer. When these heal they leave no cicatrix. 
The aphthae do not spread like the spots in ulcerative stomatitis, and 
they are distinctly painful, while the ulcers are not. 

Usually there is an increased flow of saliva accompanying 
them, the mouth is hot and feverish and the tongue heavily coated. 
Sometimes the saliva excoriates the skin and the lips are thus kept 
constantly sore. 

Thrush is a form of stomatitis occurring in children and de- 
pendent upon the grozuth of a parasitic fungus. This consists of 
long, jointed threads, the Oidium albicans, which seems to belong to 
the family of the molds. Thrush appears to be contagious. On 
looking into the mouth of young infants a layer of thin white mem- 
brane may perhaps be seen covering the palatal arch and appearing 
as white spots upon the tongue, while the mucous membrane about 
or at the borders of this coating seems to be in a healthy condition. 

Thrush in children is apt to be a sequela of chronic diarrhea, 
prolonged starvation, exhausting fevers, or any severe and debili- 
tating illness. It is indicative of and usually accompanies a low, 
atonic condition, and its cure will depend more upon feeding than 
medicines, first allaying any gastric or intestinal irritation. 

Noma, Gangrenous Stomatitis, or Cancrum Oris, is a kind of 
ulcerative stomatitis, but as the term is usually employed it implies 
a specially vicious degenerative condition, due to infection by a peculiar 
bacillus. 

The preceding remarks are more especially applicable to in- 
fantile stomatitis. The same or analogous conditions mav be, 
induced in adults by like causes. Anemic and poorly nourished 
persons are especially liable to inflammations, of the oral tissues. 
The lips are dry and parched, and superficial fissures and cracks in 
the mucous membrane appear. In a less degree this will be ob- 
servable upon the tongue, the buccal surfaces, and in the vault of 



TREATMENT OF STOMATITIS. 57 

the mouth. This may continue for some time, until finally, with the 
progression of a general febrile state, a more active stomatitis is 
developed that may result in a local breaking down or ulceration. 

Neglect of the teeth and the mouth tissues is a fruitful source 
of stomatitis in adults. Food is left to ferment and putrefy, and 
the products of this action will be exceedingly irritative to the 
soft tissues, as well as destructive to the hard. There will always 
be gingivitis present in the mouths of those who do not give 
proper attention to the removal of foreign substances from about 
the teeth, and this, by continuity of tissue, may spread all over the 
mouth. Usually the action of the saliva upon the portions freely 
washed by it is sufficient to keep them .clean and normal. But 
between and about the teeth, where food remains for an indefinite 
time, in the absence of proper care the gums are always irritated 
and more or less congested, and this may spread to adjoining 
tissue, with the result of an acute stomatitis in atonic conditions. 



CHAPTER XIII. 

TREATMENT OF STOMATITIS. 

In infantile affections the very first measures to be adopted 
necessarily imply an inquiry into the food and feeding. If the 

child is artificially fed, the nursing-bottle should be carefully 
inspected, and the food that is given must be scrutinized. If there 
is anything unsanitary about either, it must be at once corrected. 
The rubber nipple and tube must be sterilized, or, what is better, 
discarded and substituted by a new one that has been made thor- 
oughly aseptic. If the child is poorly nourished through improper 
or insufficient food, that must be remedied, and plenty of nutritious 
matter that can be readily digested and assimilated should be 
given. If there are diarrheas or other wasting disorders, which 
will too often be the case, they must at once be attended to; it 
will be impossible to build up a patient while any process of waste 
is going on. All unhygienic surroundings must be remedied, and 
the patient should be given plenty of light and air, and proper 
exercise. In short, beneficent Mother Nature, upon whom we 



58 ORAL PATHOLOGY AND PRACTICE. 

must finally rely for a cure, must be afforded every opportunity. 
Functional activity must be promoted, and all obstacles removed. 

After securing perfect sanitation the local treatment will be 
mainly depurative and stimulative. If a cathartic is indicated, 
two drams of castor oil may be administered. For the local 
irritation, a mouth-wash consisting of a solution of five to ten 
grains of chlorate of potash to the ounce of water may be used as 
a gargle. If the child is too young to use this itself, a swab may 
be made by tying soft linen to a stick of proper dimensions, and 
this may be used to apply the solution, employing a proper degree 
of friction. If the mouth is sore, it may be applied with a soft 
brush. The mouth may be occasionally washed out with the 
following preparation, especially after eating: 

3 — Borax, 30 grains; 

Sodium bicarbonate, 1 dram; 

Distilled water, 4 ounces. 

Or the following may be substituted in its place : 

I£ — Boric acid, 

Potassium chlorate, of each 15 grains; 

Lemon juice, jounce; 

Glycerol, 6 drams. 

If an antiseptic is needed, a solution of listerine, one part in 
ten parts of water, may be used in the same way, or it may be 
administered internally when diluted with simple syrup. Or the 
following may be prescribed: 

3 — Listerine (Lambert's), 2 ounces; 

Glycerol, 1 dram; 

Water, to make 4 ounces. 

Sig. — A teaspoonful after nursing or feeding. 

If there are cracks in the tongue or fissures in the cheeks, a 
solution of borax and honey, made by adding one dram of borax 
to each ounce of clarified honey, may be applied locally. 

If there are deep erosions of the mucous membrane, or ulcera- 
tive surfaces, it may be necessary to cauterize them, either with 
silver nitrate, pure carbolic acid, or chromic acid crystals. The 
last named are preferable in instances in which they can be con- 
veniently used. The cauterized places should be subsequently 
dressed with a solution of calendula. 

The treatment of follicular, or ulcerative, stomatitis in adults 



TREATMENT OF STOMATITIS. 59 

does not materially differ from that in infants, except that more 
active measures may be used. The remedies may be proportionately 
increased in strength, and personal care insisted upon. The teeth 
should be thoroughly cleaned, and all broken or sharp edges re- 
moved. A soft tooth-brush should be employed after every meal, 
and with it should be prescribed some antiseptic wash. A two* per 
cent, solution of zinc chloride may be used as a gargle. At night a 
spoonful of Phillips' milk of magnesia should be taken into' the 
mouth and rinsed about all the teeth, to be left upon them until the 
morning. Enough of good nourishing food should be given, and 
the patient should have plenty of pure air and sunshine. 

There is a form of ulcer that is the result of the careless appli- 
cation of arsenous acid in the devitalization of teeth, which may 
be referred to in this connection. Arsenic is a corrosive poison. 
It produces its characteristic effects in destroying the pulps of 
teeth through its corrosive action, and not through congestion and 
the production of consequent stasis at the apical foramen, because 
it will promptly kill the pulp of a partially developed tooth in which 
the root is entirely open, no foraminal constriction having yet been 
formed, and in which strangulation is therefore impossible. When 
arsenous acid is insecurely sealed up in the cavity of a tooth, such a 
defective agent as cotton wet with a solution of gum sandarac being 
employed for that purpose, it may come in contact with the buccal 
tissue and devitalize that as it does the pulp, gradually eating its 
way in until a considerable slough is produced. 

When this is the case, the ulcer should be thoroughly satu- 
rated with dialyzed iron, to limit the action of the arsenic. It 
should then be dressed with a solution of calendula, and kept clean 
and aseptic until it has healed. Should the corrosive effects be 
manifest between the teeth and reach to the alveolar bone, it will 
probably induce an osteitis that may end in caries or necrosis. 
When this is the case the affected bone should be promptly burred 
away before using the dialyzed iron. 

In Gangrene, or Noma, or Cancrum Oris, thorough cauteriza- 
tion or removal of the affected tissue will probably be necessary, 
and the strictest antiseptic precautions must be employed. For the 
general symptoms constitutional treatment must be taken. Tonics 
should be employed, with fresh air and a sufficient amount of 
exercise. Every possible effort should be made to promote nutri- 



60 ORAL PATHOLOGY AND PRACTICE. 

tion, and especially that of the locally affected tissues. In fact, 
when stomatitis reaches the point of deep ulceration or extensive 
breaking down of tissue, it is such a grave condition that general 
constitutional treatment should not be delayed. 

Sometimes the pulps of teeth assume a gangrenous condition. 
When this is the case, there is great danger that septicemia and 
pyemia may be the consequence. Miller details a number of cases 
within the sphere of his own observation, in which death within 
a very few days has been the result of the gangrenous infection 
of a tooth pulp. When the symptoms of general septic poisoning 
are manifest, no time should be lost in the institution of the proper 
general remedial measures, the consideration of which is beyond 
the scope of this work. 

In cases of thrush in infants that are badly or insufficiently 
nourished, there is usually more or less of gastric or intestinal irri- 
tation in connection with the markedly atonic condition. This will 
probably require the administration of such correctives as rhubarb 
and soda, lime-water, and vegetable bitters. When the aphthae 
occur in older persons they are often spoken of as "canker spots," 
or "canker sore mouth." The usual treatment is roughly to cau- 
terize the spots and dress them with a solution of calendula. If 
an active cauterant is not desirable, as in children, the aphthous 
patches may be repeatedly touched with the following solution: 

I£ — Sodium salicylate, i dram; 

Distilled water, 6 drams. 

Or in place of the preceding this may be used-: 

I£ — Borax, 45 grains; 

Sodium salicylate, 75 " 

Tinct. myrrh, 1 dram; 

Simple syrup, 
Distilled water, of each y 2 ounce. 

If the aphthae exist in considerable numbers, they may demand 
the use of antiseptic mouth-washes. If they are the consequence 
of a general anemic condition, tonics and alteratives are of course 
indicated. While they are peculiarly uncomfortable, the aphthae 
have no serious pathological signification, except as they are in- 
dicative of an atonic condition. 



PHARYNGITIS AND TONSILLITIS. 6l 

CHAPTER XIV. 
PHARYNGITIS AND TONSILLITIS. 

There are many pathological conditions of the oral cavity, 
and of the immediately connected tissues and organs, that should 
fall within the province of the oral physician or dentist, but which 
are usually relegated to the general medical man. When the time 
shall come in which no man will be allowed to enter upon oral 
practice who is not thoroughly qualified to treat all oral condi- 
tions, dentistry will occupy a very different place in general esti- 
mation from that of to-day, and there will be plenty of room for 
all the competent men whom it will be possible for the colleges 
to turn out. At present, diseases of the pharynx are usually sup- 
posed to be beyond the scope of the dental practitioner. And yet 
there are no specialists to whom such affections should so naturally 
fall, and there are none who have such opportunities for the observa- 
tion and detection of pharyngeal lesions. It but needs that these 
shall be brought within the limits of his practice, and that he shall 
properly qualify himself for their treatment, to bring great benefits 
to both the dentist and the people. 

The pharynx is a pouch, largely aponeurotic, which is divided 
into two parts by the soft palate. It has seven openings — that of the 
mouth, the two Eustachian tubes, the larynx, the esophagus, and the two 
nares. Its diseases are mainly those of the mucous membrane. There 
is no more common affection than angina simplex, a common 
sore throat, the effect of that inflammation that we call a cold. 
It is accompanied with irritation, huskiness, and pain in swallow- 
ing, and its remedy is in cleansing, antiseptic, astringent-stimulat- 
ing, and anodyne gargles, a solution of chlorate of potash being that 
most commonly used. 

A considerable proportion of pharyngeal affections are the 
direct results of lesions within the oral cavity, brought about by 
continuity of tissue. There are certain diseases of the tonsillar 
glands that are not included in this origin, and there are inflamma- 
tions dependent upon laryngeal lesions as well, but a considerable 
number of the affections are due to oral trouble. Complications 
arising from impactions of the wisdom tooth and its investments 



62 ORAL PATHOLOGY AND PRACTICE. 

are one of the most frequent of these. Owing to a lack of develop- 
ment, especially in the length of the body of the lower jaw, fre- 
quently there is not sufficient room for the eruption of the tooth, 
and it becomes imbedded in the tissues, a constant source of irri- 
tation. Sometimes the inflammation about it is so intense as to 
prevent the opening and closing of the mouth. At times there is 
a breaking down of tissue, and suppuration ensues. From the 
initial point of the lesion, dark-red lines extending down into the 
pharynx may be observed, and there is a distinct and sometimes 
an acute inflammation of the pillars of the fauces, with great dis- 
comfort, or even acute pain. 

In cases of cleft palate there are almost always complications 
involving the anterior and posterior nares. When these are pre- 
sented to the dentist he usually proceeds to the construction of some 
prosthetic apparatus for the purpose of supplying the loss, without 
any preliminary attention to the soft tissues themselves. In all 
cases of complete or incomplete cleft, the pharyngeal walls, as well 
as those of the nasal cavity, are in an irritable, inflamed, hyperemic 
state. This could not well be otherwise, because they are not pro- 
tected by the usual palate, and are subjected to the irritating action 
of food and drink every time it is taken. Not infrequently there 
are excoriations and abrasions of the edges of the palatal cleft, with 
degenerative conditions of the mucous membrane of the posterior 
nares that require active treatment. The oral physician or surgeon 
seldom notices them, because they do not form a part of the regular 
practice to which he confines himself. 

Inflammations of the pharyngeal tissues, arising from the 
changes in the neural currents commonly called "taking cold," are 
quite common. If the tongue is depressed by placing upon it a 
broad spatula, the whole pharyngeal cavity will appear of a bright- 
red color, with the parts considerably swollen. The uvula will 
appear lengthened and pendulous. There will be a dryness in the 
fauces, with huskiness of the voice and considerable pain on swal- 
lowing. The Eustachian tube will apparently be closed, and the 
hearing will be materially affected. 

These simple follicular inflammations usually result in a ready 
resolution, but their time may be cut short by proper remedial 
measures. If there are no abscesses or deep erosions, hot pedi- 
luvia should be resorted to, with saline cathartics and diaphoretics. 



PHARYNGITIS AND TONSILLITIS. 63 

The latter class of remedies is of importance, and a general 
diaphoresis will usually greatly hasten a cure. Twenty or thirty 
grains of potassium bromide, with five drops of tinct. veratrum 
viride, may be taken in a small glass of water, when the patient 
should go to bed and cover up warm. A gargle of chlorate of 
potash may be used if the attack is not very acute. If there is any 
infection, an antiseptic gargle, such as a teaspoonful of phenol 
sodique in a glass of water, or five grains of chloride of zinc to the 
ounce of water, may be employed. If there are excoriated surfaces 
they may be touched with a cauterant. 

Tonsillitis. 

The tonsils are sometimes severely attacked by parenchyma- 
tous inflammation. Where this is comparatively slight, a careful 
examination may be necessary to distinguish it from some forms 
of pharyngeal inflammation. But there are instances in which 
the tonsils become so greatly inflamed as to prevent swallowing 
and to impede breathing, and active scarification becomes a neces- 
sity. Usually, however, the swelling may be allayed by a phenol- 
sodique gargle, or one of which sodium bicarbonate forms the 
base. If there is much pain the tonsils may be painted over with 
a cocain solution. If suppuration ensues despite all measures to 
prevent it, the pus should be voided as soon as possible, and the 
usual antiseptic treatment follow. 

In tonsillitis of an especially acute character Prof. F. J. S. 
Gorgas recommends the following prescription: 

^ — Acidi gallici, gr. xl; 

Liq. sodse chlorinatse, oij ; 

Glycerol, Eij ; 

Aquas dest, Bviij. M. 

Sig. — To be used as an antiseptic and astringent gargle. 

It should not be forgotten that the tonsils are frequently 
marked with deep sulci and furrows, especially if they have been 
the seat of repeated attacks of septic inflammations. These de- 
pressions form favorable harbors for the proliferation of different 
forms of pathogenic and saprogenic bacteria. When this condi- 
tion is observed, great care should be exercised to keep the exter- 
nal surfaces of the glands in an aseptic condition, lest the sup- 
purative condition commonly called quinsy become chronic. 



64 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XV. 
DISEASES OF THE TONGUE. 

Properly read, the appearance and superficial condition of the 
tongue is an index to most gastric and to many other general dis- 
turbances. In health it is of a delicate whitish pink color, smooth 
and moist. Any departure from this appearance indicates a patho- 
logical condition, not necessarily of the organ itself, but of others 
whose disturbed state is reflected upon the tongue, and especially 
of functional aberrations which interfere with digestion. It may 
be covered with the so-called "fur," which is a coating made up of 
the epithelial scales that have not been thrown off, of certain gran- 
ular matters, of inspissated or degenerate mucus, and of detritus. 
The investment of the tongue with this coating always commences 
at its base, and gradually invades the dorsum until the tip is 
reached. The clearing up of the tongue during convalescence is 
from the tip and borders toward the base, so that the progress or 
recession of this coating will furnish an index to the condition of 
the patient from day to day. A furred tongue is a symptom of a 
defective circulation. 

In addition there are certain well-established appearances that 
are indicative of special pathological conditions : 

Extreme humidity — Indicates atony, with anemia. 

Extreme dryness — Nervous irritation or weakness. 

Flabbiness or tremulousness — Extreme weakness. 

A grayish white color after eating — Normal digestion. 

A yellowish white — Acidity, with biliary irritation. 

Very white, thick coating (''flannel mouth") — Intense venous 
congestion. 

A delicate pinkish red — Digestion completed. 

A deeper hue of red — Arterial congestion; irritation. 

Very deep dark red — Active inflammation. 

Bright red, razv or glazed — Approaching fatal exhaustion. 

Brownish red, with thick dry coating — Prostration; danger. 

Black, not a deep hue — Blood poisoning; pyemia. 

Bluish tinge — Cyanosis; lack of oxygen. 

The indications upon the tongue of a dangerous condition are 



DISEASES OF THE TONGUE. 65 

tremulous action, extreme dryness, blueness, a very red, shining or 
glazed aspect, and heavy furring of a dark or black hue. 

In considering the tongue as a diagnostic organ, however, its 
indications are not to be depended upon alone. Its appearance 
should always be studied in connection with other symptoms, 
which -may dominate the decision. It is to be considered only as 
an important auxiliary in arriving at a conclusion. 

Of itself the tongue is subject to many pathological conditions. 
It is manifestly impossible within the limits of a work like this to 
consider all these, or to do more than to note those degenerations 
that are of greatest interest to the oral specialist. The remainder 
more especially belong to the general practitioner. 

Glossitis, inflammation of the tongue itself, whether sympa- 
thetic or idiopathic, is a disorder which may occur at any time. 
When it is the result of some injury or traumatism, it especially 
appeals to the oral practitioner. The tongue may be wounded by 
the careless use of instruments, and great inflammation may be the 
result. An excavator or bur that has been used in a gangrenous 
tooth pulp may wound the tongue and cause alarming symptoms 
as the result of the septic infection; a very short time may suffice 
to cause such an intense infiltration that suffocation will appear 
imminent. The swollen tongue may fill the mouth to the utmost 
point of distention. The general system may sympathize and the 
pulse grow rapid, a feverish condition supervene, and a state ensue 
that causes the most intense anxiety, from the alarming symptoms 
presented. 

An acute glossitis will usually, however, end in complete reso- 
lution without such startling symptoms. It may be necessary, 
and it is usually advisable, to administer an active cathartic, and to 
promote diaphoresis by means of potassium bromide, or Dover's 
powders, with warm drinks. If there is a septic wound it should 
be opened to its bottom, to permit the escape of any infectious 
products. If the swelling assumes dangerous proportions, no 
time should be lost in making deep incisions into the body of 
the tongue. These should not be long or continuous, but merely 
deep punctures with a bistoury, and as many as may seem indi- 
cated. 

Syphilitic ulcers, swellings, cracks and fissures, indurations, 



66 



ORAL PATHOLCGY AND PRACTICE. 



hypertrophies, etc., are comparatively common, but their consid- 
eration need not engross our attention at this time. 

Fig. 14. 




The Tongue. 
1. The Circumvallate Papillae, or Papillae Maximae. 2. The Foramen Cecum. 3. Fungi- 
form Papillae, or Papillae Mediae. 4,5. Filiform Papillae, or Papillae Minimae. 6. Inter- 
tonsillar space, with numerous follicles. 7. The Tonsils. 8. The Epiglottis. 9. TheFrenum. 



Injuries from the teeth are not uncommon, and sometimes 
result in degenerative conditions of the gravest character. The 

tongue is perhaps irritated by the sharp edge of a decayed or 
broken tooth, and a thickening of the tissue, with induration, fol- 



DENTITION : GENERAL CONSIDERATIONS. 67 

lows, even though the mucous membrane is not broken. The 
irritation being kept up, the scirrhosis increases until there comes 
a time when it breaks down in the center, an indurated border yet 
remaining. This may present the appearance of syphilitic gum- 
mata, and may have consequences almost as disastrous. No dentist 
should leave in the mouth any such tooth, if it falls under his obser- 
vation, for it may result in a serious complication. When such a 
thickening is found all source of irritation should be removed, and 
if it does not disappear it may be necessary to remove it by surgical 
interference, lest it assume a malignant form. 

If an eroded ulcer is the result of such a sharp tooth, and if 
upon removal of the cause it presents an indolent appearance, a 
chloride of zinc wash of not more than ten grains to the ounce of 
water may be used, or one made by the addition of a little compound 
tincture of capsicum in water. Violent, or drastic, or surgical 
measures should not, however, be lightly resorted to. Plenty of 
time should be given for nature to bring about a cure, and general 
measures, like tonics and alteratives, should be resorted to, lest too 
active local interference bring about the very state that it is desired 
to avoid. 



CHAPTER XVI. 

DENTITION: GENERAL CONSIDERATIONS. 

The subject of dentition has not heretofore received the 
thoughtful consideration at the hands of either dentist or physician 
which its magnitude warrants. The general practitioner is apt 
either to consider it a mere physiological process which demands no 
attention whatever, save in a few very exceptional instances super- 
ficially to lance the overlying gum, or without special deliberation 
heedlessly to charge to its account almost any of the disorders which 
occur coincidentally. On the other hand, the dentist, like all other 
specialists, is inclined to discover within the limits of his own field 
the proximate or direct cause for almost every ill to which flesh is 
heir. This is but natural. His life is devoted to the study of 
certain organs, and he knows how close is their functional relation 
to other parts of the body. He is certainly more likely to be right 



68 ORAL PATHOLOGY AND PRACTICE. 

than the man who has no special or intimate knowledge of that 
particular subject, but there is danger that he may exaggerate its 
importance as one of the factors in vitality. That which is nearest 
our eye may eclipse much larger but more distant objects. To 
learn their proper relative importance a view must be taken from 
another standpoint. 

The purpose of this chapter is to determine, as far as possible, 
the influence of the advent of the teeth upon other functions of the 
body, to point out the complications which may arise in their 
growth, and to correct the impression so often conveyed by physi- 
cians that disorders in no way related are the result of a dentition 
which may be entirely normal. The author is but too well aware 
that he is not, on this question, in entire accord with either the 
average dentist or physician, the one, as he believes, too often 
exaggerating, and the other misapprehending its functional signifi- 
cance. If, therefore, he assumes to speak in a somewhat contro- 
versial manner, it is that he may consider the subject from another 
than his own standpoint. Let there be no misconception. He does 
not in any way wish to be comprehended as urging that dentition 
is but a minor matter, or that its possible importance has been in 
any way, by anyone whatever, overestimated. It is, however, quite 
possible that inquiry has been wrongly directed, and that the scope 
of its influence has been in some instances misconceived. 

The period of dentition is a transitional one. It is the time 
when, under normal conditions, the child is gradually habituated to 
the reception of food that is extra-maternal, — that which has not 
already by the mother been digested and transformed into a pabu- 
lum which is adapted to the undeveloped organs of the infant. 
It should be comprehended that during this period it is not alone the 
teeth which are growing. Organs are developing simultaneously 
that are far more important, in that they are absolutely essen- 
tial to life itself, and without which existence cannot even for a 
short time be maintained. If it is true, then, that the development 
of the teeth under usual conditions is likely to produce such seri- 
ous disturbances as are sometimes charged to it, what shall be said 
of the growth and functional changes taking place in the digestive 
tract, and what of that marvelous transformation in the heart which 
occurs at birth, or that of the genital organs which takes place later 
in life? We must not fall into the error of attributing to the 



DENTITION : GENERAL CONSIDERATIONS. 69 

growth of the teeth all the phenomena of the period, ignoring the 
fact that other organs are passing through a like developing stage. 
It must be remembered that the beginning of the formation of the 
teeth goes back to a very early period of fetal existence, and is 
contemporaneous with that of the heart and the lungs. The mere 
eruption of them through the gums is but a single incident in their 
progression, due to rapid growth of the cementum and dentine, 
and is simply one of the eras of spasmodic developmental activity 
through which all bodily organs pass. Why should such infinitely 
greater stress be placed upon the advancement of the teeth than 
upon that of all the other organs of the body, when, as is presup- 
posed in the preceding paragraphs, no specially abnormal or un- 
usual conditions exist? 

That anomalous and unnatural presentations of the dental 
organs are more common than are lesions in other like developing 
ones is undoubtedly the case, and it is from this standpoint, and 
from this alone, that the magnitude of the subject is apparent. 
But that, grave as may be the complications which produce certain 
definite functional disturbances, to them shall be attributed the 
most diverse disorders, and those whose etiology may be so much 
more readily discovered in other functional disturbances, seems not 
very reasonable or rational. The sole question at issue is not 
whether dentition may induce grave systemic disorders, but whether 
it is responsible practically for all of them. There can be no denial 
of the fact that it may produce serious reflex complications. 
Phimosis may do the same, but is it possible that either is the cause 
of those whose origin is in direct instead of reflex influences? 
Children may, and often do, die from maladies induced by teething. 
But is that solely, or even chiefly, responsible for the terrible mor- 
tality of childhood? That is the problem to which this and the 
three succeeding chapters are devoted. 

It is urged that infant mortality may be very largely due to the 
lowering of vitality, and a diminution of the resistive force of the 
healthy body against disease. That the reduction of the vital 
potential caused by the nervous strain incident to irritation of the 
dental papillae may so weaken function that when any digestive 
irritation is encountered the little patient at once succumbs, — this 
must be conceded by all. But to make of it the principal factor in 
the great mortality of childhood, the exclusive view of the specialist, 



JO ORAL PATHOLOGY AND PRACTICE. 

to which objection has already been raised, must be adopted, and 
the developmental disturbances which may arise in all other organs 
must be ignored. It also assumes that in a large proportion of 
instances dentition is abnormal, an hypothesis that is by no means 
proved. In this view it would appear that the influence of denti- 
tion in causing the digestive disturbances to which the great mor- 
tality of infancy is so largely due may very easily be exaggerated. 
That in reflex nervous action may be found the origin of many 
infantile as well as adult disturbances it is one of the objects of 
these chapters to demonstrate. No physiologist or pathologist of 
intelligence and reflection will be likely to lose sight of this. But 
it is also the object to draw a line between disorders that evidently 
are or readily may be due to direct functional disturbances, and 
those which are more recondite in their etiology. Reflex dis- 
turbances will induce reflex symptoms, and the student is herein 
urged to* consider them very carefully. He is taught to distinguish 
between the reflex and the direct, and that principal object is kept 
steadily in view. The appearances objectively presented when 
dentition is not proceeding normally are detailed, and the symptoms 
which reflex nervous action will offer are considered. If a diarrhea 
can in any way be traced to dental irritation, no one will dispute 
that it must be through reflex nervous conditions, nor that it must 
present or be accompanied by reflex symptoms. That is the sole 
point at issue. Shall we in discrimination inculcate the importance 
of distinguishing between the two, or shall we, without any special 
study of the case or consideration of the circumstances, continue to 
attribute to that which may be proceeding normally disturbances 
in other organs in which we know function to be deranged ? Chil- 
dren may die of digestive disorders induced through reflex dis- 
turbances of dentition. The sole question is, Can we charge to this 
sole cause all the frightful mortality of childhood, when we should 
know but too well that other more powerful factors are engaged ? 



THE DISEASES OF DENTITION. 7 1 

CHAPTER XVII. 
THE DISEASES OF DENTITION. 

The fact that a considerable portion of the human family die 
before they have reached the period at which the last of the 
deciduous teeth shall have been erupted, and that the time of 
greatest mortality is that during which the teeth usually make 
their appearance, has led to the popular belief that the one is 
necessarily dependent upon the other; that dentition is the almost 
exclusive cause of the high death-rate among children, instead of 
more frequently being merely coincidental. That it is possible for 
a retarded or disturbed dental development to induce very serious 
derangement has already been affirmed, but that it is the principal 
factor in inducing the great number of deaths that occur in children 
from digestive disorders can scarcely be maintained. There are 
many cogent reasons for the contrary belief, while there is nothing, 
save the mere fact of coincidence, to sustain the theory too com- 
monly accepted without inquiry or consideration. 

There is a lack of comprehension as to the true character of 
the diseases that cause this high death-rate in children. Digestive 
derangements are not the main factor, and yet, if we except 
nervous disorders, these are the only ones that can with propriety 
be urged as the possible result of disturbances in dentition. 
Statistical summaries nowhere give the cutting of teeth as a cause 
of death. Although the reflexes due to disordered dentition un- 
doubtedly in some instances may be the real proximate, if not the 
direct, cause of death, it is impossible always to distinguish them 
from other reflex disturbances, and, in any case, statistics cannot 
pretend to present more than the immediate cause. Hence they 
must always be accepted with these limitations. But, the fatal 
lesion being determined, it is comparatively easy to discover whether 
reflexes may readily induce it, and from these probabilities deter- 
mine their influence in any given table. For instance, no one will 
urge that they can play any important part in the zymotic disturb- 
ances which are chiefly chargeable with the majority of infantile 
deaths, while in affections of the brain, heart, or kidneys they might 
be frequently responsible. But granted that a brain trouble is due 
to reflex irritation, it is by no means established that the source 
lies in the teeth. 



J2 ORAL PATHOLOGY AND PRACTICE. 

The following tables will be found very instructive in the 
study of mortality. They are derived from reliable sources, and 
are presented in the hope that they will afford assistance to those 
who desire to investigate for themselves, rather than to obtain all 
their information at second-hand. The traditionary instruction 
given in medical schools is that the teeth are the one important 
factor in producing the high death-rate of infancy. It is the 
imperative duty of dentists to examine the facts, and to inquire if 
this hypothesis is not founded in error, due to insufficient study and 
knowledge, like that other assumption of certain medical authori- 
ties, that pulpless teeth are the principal source of disease of the 
maxillary sinus, and a continual menace to health. 

Percentage of probability that a child born alive will die 
of different diseases. 

Phthisis 1144 Diphtheria 0049 

Diarrhea and dysentery 0343 Brain diseases 1218 

Typhoid 0381 Lung diseases 2640 

Scarlet fever 0300 Stomach and liver diseases. . . .0524 

Whooping-cough 0151 Heart disease and dropsy 0766 

Measles 0128 Kidney diseases 0149 

This shows that diseases of the lungs, which include phthisis, 
are the most fatal, and that more than twice as many people die 
of brain disease as of stomach troubles. 

Mean age at death of people dying from various diseases. 

Males. 

All causes 28.2 

Whooping-cough 1.7 

Measles 2.5 

Croup 3.1 

Diphtheria 7.7 

Scarlet fever 5.2 

Smallpox 13.2 

Diarrhea 11.8 

Cholera 30.4 

Erysipelas 35.7 

Rheumatism 39.8 

Influenza 42.8 

Carbuncle 59.2 



Females. 


Mean. 


30.8 


29-5 


1.8 


1-75 


2.8 


2.7 


3-2 


3.15 


8.1 


7-9 


5-6 


5-4 


10.6 


II.9 


14.9 


134 


32.4 


31.4 


32.8 


34-3 


41.4 


40.6 


48.8 


45-8 


57-2 


58.6 



THE DISEASES OF DENTITION. 



73 



This table indicates that the diarrheas are not confined to 
childhood, but that they are most destructive in middle life. 

Average infant mortality in different countries. Percentage of the 
population dying under five years of age. 

Norway 17 France 31 



Ireland 17 

Denmark 20 

Scotland 20 

Sweden 20 

England 26 

Belgium 2j 



Prussia 32 

Holland 33 

Austria 36 

Spain 36 

Russia 38 

Italy 39 



This table shows that in the warmer and more thickly popu- 
lated countries infant mortality is greater than in those lying 
farther north, and which have fewer people to the square mile. 
In this connection the following table will be of interest: 

Death-rate per 1000 under increase of the population to the square mile. 

Population to sq. mile 166 186 379 1,718 4,449 12,357 65,823 

Death-rate at all ages 16.94 19.18 21.90 24.81 28.02 32.96 38.67 

Under 5 years 37-8o 47-53 63.06 82.10 94.04 11 1.90 139.52 

This table shows that with an increase in population the 
death-rate in young children is very much greater than in adults. 

Number of births in the several months of the year in different 

countries, 100 being considered the general 

normal average. 

France. 

January 105 

February in 

March 109 

April 106 

May 99 

June 95 

July 96 

August 96 

September 97 

October 95 

November 97 

December 95 



rmany. 


Spain. 


Italy. 


103 


114 


I07 


105 


108 


114 


IO3 


112 


no 


100 


I02 


106 


97 


IOO 


95 


95 


89 


89 


96 


88 


9i 


98 


9i 


93 


106 


98 


100 


100 


IOO 


98 


100 


97 


98 


99 


IOO 


97 



74 ORAL PATHOLOGY AND PRACTICE. 

It is only in the older countries that these statistics, which 
are compiled from government records, are kept. In America 
the census reports have not until lately been thus complete. The 
lesson to be learned from these presentations is, that while birth- 
rates do not widely differ, the death-rate is subject to many contin- 
gencies. The diseases of which children mostly die are not those 
which could be materially influenced by the cutting of teeth, but 
are due either to organic lesions or to contagious disorders, in 
neither of which can dental disturbances play any important part. 
As has already been stated, nowhere is the cutting of teeth statisti- 
cally given as the direct cause of mortality. Although it may in 
some instances induce death through some other complication, its 
influence has been considered either too remote or too insignificant 
to be included as a separate cause. 

All these facts should lead us to give close scrutiny to the 
assertions of those who claim that any considerable number of 
infants die from cutting teeth. A distinction should be clearly 
drawn between the "so-called" diseases of dentition, which may be 
digestive disturbances, and those that are actually produced by 
mal-development of the teeth, whose pathological history is quite 
different. The former class of derangements may properly 
belong to the general practitioner, while the attention of the oral 
pathologist should be more particularly directed to the latter. But 
as it is essential that both should be comprehended to make a clear 
diagnosis, each must in turn be considered, and they will for con- 
venience be divided into the "so-called" and the "true" disturb- 
ances of dentition. 



CHAPTER XVIII. 

THE SO-CALLED DISEASES OF DENTITION. 

Those which we may denominate imputed diseases of dentition 
are the diarrheas, dysenteries, and fevers of infancy, which are 
true digestive disorders, and instead of having their etiology in 
the advancing teeth, arise from improper feeding during the period 
of most active development. All growth, whether in the vegetable 
or animal kingdom, is by alternate periods of activity and repose. 



THE SO-CALLED DISEASES OF DENTITION. 75 

In plants, winter is the season of rest and of the gathering of 
forces for the season of advancement. With the spring comes 
the period of growth, when the organism assumes an extraor- 
dinary energy. The leaves are put forth, and each twig shoots 
out with an amazing activity. The whole advance of a year is 
then made within a few weeks. But the tissue so developed is 
soft and succulent, without the woody structure that gives it 
strength and consistency. The summer, when increase and exten- 
sion have ceased, is devoted to the maturing and consolidation 
of the newly formed material, while in autumn all the energies 
of the plant are employed in perfecting the fruit or seed by which 
the preservation of the species is insured. 

The growth of the plant is analogous to that of the animal. 
Vegetable physiology does not in essence differ from that of the 
sentient being. The latter has also its periods of increase, of active 
expansion, and those devoted to the maturing and perfecting of 
that already formed. Many people have observed that children, 
after a period of seeming suspension of development, may within 
a few months add an inch or more to their stature. This is suc- 
ceeded by another term of rest, when the tissues pass through a 
process of maturing. It is well known that during these terms of 
rapid growth young persons are more liable to injuries and illnesses 
of different kinds than they are either before or after them. It 
should not be forgotten that the teeth, like the other organs of the 
body, have their distinct eras, and that they develop with the rest 
of the body, and not independently of it. When the child is cut- 
ting its teeth, at the same time it is practically getting a new 
stomach and new digestive organs. Local causes aside, if the 
muscles do not develop, the jaw and teeth will not grow, for all 
are dependent upon the same digestion and assimilation of food. 

In the newborn infant none of the tissues are sufficiently 
developed to perform independent function. The muscles of the 
legs will not support its weight, and those of the arm are not suffi- 
ciently advanced to give it co-ordinate action. The nutritive 
apparatus is as yet so imperfectly organized that it cannot fully 
digest food, and the child must be given pabulum that is already 
partly prepared for assimilation. It finds this in the greatest per- 
fection in the milk of the mother, in which all the elements necessary 
to growth are held in solution in a condition exactly adapted to the 



y6 ORAL PATHOLOGY AND PRACTICE. 

state of development of the child. At birth this milk is less highly 
organized than it will be six months later. When the physician 
seeks a wet-nurse for a newly born infant, he does not choose 
one whose child was born six months previously, because her milk 
would be of such a character that the weak organs of the young 
babe could not finish its digestion. The milk of one who has been 
a mother for two months would be too highly organized for the 
babe of a week. 

Nature has made all provision for the regular development 
of the child, and as its digestive organs become better developed 
the milk of the mother changes accordingly, until by regular 
progression, through successive advancing periods of growth, the 
various organs are sufficiently perfected for independent existence, 
and food that is partially digested is no longer a necessity for 
healthy functional action. This will only, in normal conditions, 
occur when the other organs are as far advanced as the digestive 
tract. The muscular system will have enough strength to enable 
the child to perform necessary motion. The brain and intelli- 
gence will be adequate to the proper selection of its food, while 
the teeth will be in a sufficiently advanced state to prepare the 
pabulum that is proper for its condition. As after this the body 
gradually develops, so that more highly organized food becomes 
a necessity, additional teeth are given, the small ones of childhood 
are succeeded by those larger and stronger, until with the period 
of full puberty the dentition is completed simultaneously with the 
perfection of the other organs. 

Unless the regular gradation of food keeps pace with the 
evolution and progressive growth of the organs, all the processes 
of nature are deranged, function is interfered with, and disease is 
the result. If the young child, with its digestive apparatus but 
little developed, is given food too highly organized, indigestion, 
with its consequent vomitings, diarrheas, and febrile disturbance, 
will be the result, and it is here that the "so-called" diseases of 
dentition largely have their origin. With the advent of the decidu- 
ous incisors, the muscular system is sufficiently advanced to allow 
the child to sit erect, and in the average family it is taken to the 
table at meal-time. The injudicious or ignorant mother places in 
its mouth some soft food, fit only for adults. The instinct of the 
child teaches it to reject the offered dainty. The sense of taste 



THE SO-CALLED DISEASES OF DENTITION. JJ 

has not yet been wholly developed, nor will it be normally until 
the organs are sufficiently advanced for full digestion, and so the 
morsel is ejected with a wry face. But the mother persists, and 
after a time it is swallowed. Perhaps a morbid, abnormal appetite 
is stimulated, much as later in life one for whiskey or tobacco or 
opium is acquired. 

The bolus having been swallowed, it must lie in the ele- 
mentary stomach as undigested as if it were leather or rubber. 
It is perhaps regurgitated, and thus expelled from the system. 
If the bad feeding is persisted in, this means of rejection is soon 
exhausted, and the foreign matter remains in the stomach, a 
continual irritant, until it is violently passed through the pyloric 
opening and into the tender duodenum. Thence, by its irritating 
action as a foreign substance, it induces the violent peristaltic 
movements which, when kept up by successive invasions of the 
irritant, become a pronounced diarrhea, possibly to degenerate into 
a dysenteric condition, with final death. 

And this, because it occurs about the period when the teeth 
are erupting, is ascribed to dentition. As well might puberty in 
the male be imputed to the growth of the whiskers, because they 
begin to appear at about this time. It is essential that the oral 
pathologist should have correct views upon this subject, and hence 
some time must be devoted to its consideration. There are a 
number of cogent reasons why the prevailing belief among physi- 
cians that diarrheas and other digestive disturbances are due to 
advancing teeth is erroneous. 

In the first place, their connection is remote, while that be- 
tween the diarrheas and improper feeding is so close that the proba- 
bilities are greatly in favor of it as the cause, even on other than 
physiological grounds. 

The growth of the teeth is as much a physiological process 
as is that of the hair or nails. Their development commences 
some time before birth, and continues for a long time after it. 
The mere erupting of the organs is but an incidental step in the 
process, and by no means its most significant or important one. 
Why should the growth of the teeth not induce disturbances of 
nutrition before birth, if it does after? 

The so-called diseases of dentition are confined to a compara- 
tively small portion of the year, and that is precisely the period 



78 



ORAL PATHOLOGY AND PRACTICE. 



when a change in the food of infants is most liable to be made in 
the average family, while dentition goes on all the year alike. 

There are as many teeth cut in January as in July, but the "so- 
called" diseases of dentition are as one to a hundred. This is 



Table I. 

Death-rate, from All Causes, of Children under Three Years, in the 
City of Buffalo, for the Years 1888, 1889, and 1890. 



AV. TEMP. 


JAN. 


FEB. 


MAR. 


APR. 


MAY 


JUNE 


JULY 


AUG. 


SEPT. 


OCT. 


NOV. 


DEC. 


DEATHS 




72° 


























378 




70 














/? 


>° 










364 




68° 


























350 




66° 












/ 
/ 














33& 




64° 












jfo 


»327 


y 


r« 








322 




62 












f 


1 3 


23 v 


1 








30S 




6o° 












/ 






\" 


>° 






294 




58° 










1 
1 


t 






• 








280 




56° 










1 








I 1 








266 




54° 










/* 


O 






V t 








252 




52° 










I 








1 


1 






238 




50° 










# 

/ 




2 


?5 V 


1 
\ 






224 




48° 










1 








\ 

\ 






210 




46° 








1 

I 












\4~ 


O 




I96 




44° 








1 

I 


179 














182 




42° 








1 

I 












\ 1 






168 




..J2L. 


■ T-1--1 


m m m 


» » s • 


•te 


y \ 


1/ 


JWW6 


f mw 


frHLy 


vW> 


iyry. 




.154— 




38 








J& 










l£ 


V 


V33 


s 


140 




36 




i3o 


Jli^ 


t 


















126 




34° 


125 




i 














II 


6 s *-! 


II* 


112 




32° 






1 






112 












\ 


98 




30° 






1 

1 


















V3I 


1 84 




28 






1 
119 


,s° 


















70 




26° 


\ 27 

\ 





/ 




















56 




24° 


< 


v' 






















42 




22° 




T24 






















28 




20° 


























14 





The inte 



rrupted line indicates the average temperature, the continuous line denoting the rise 
and fall of the death-rate. 



THE SO-CALLED DISEASES OF DENTITION. 



79 



Table II. 

Mortality from Diarrheal Diseases in the City of Buffalo for the 

Years 1888, 1889, and 1890 for the Months Named. 



AV. TEMP. 


MAY 


JUNK 


JUI.Y 


AUG. 


SEPT. 


OCT. 


NOV. 


DEATHS 




70° 






tR? 


12 








217 




6 9 ° 






/IV 








210 




68° 






1 I X 

1 1 


\ 








203 




67° 




/ 




V 7 ° 








I96 




66° 




/ 




I % 








189 




65° 




fes c 












182 




64° 




* 




V74 \ 








175 




63° 




1 




A 


% 






168 




62 




i 






% 






l6l 




6i° 




t 






% 
% 






154 




6o° 




i 






% 

\60° 






147 




59° 


1 








t 

1 






140 




58° 


1 
f 








1 

% 






133 




57° 


1 






1 
1 






126 




56° 


1 






1 






119 




55° 


• 
* 






I 
1 






112 




54° 


iV 








\ — ■ • 






105 




53° 










1 1 


1 




9 s 




52° 












1 

% 




91 




5i° 










\82 


1 

1 




84 




50° 












1 




77 




49° 












1 
1 




70 




48° 












1 
1 




63 




47° 












1 

\A7° 




56 




46° 












L % 




49 




45° 












\ % 




42 




44° 












V36** 




35 




*43° 
















28 




42 




J 24 










\ 


21 




41° 
















14 




40° 


*9 












% X9 


7 




39° - 














^39° 




■ 



The interrupted line indicates the average temperature, the continuous line denoting 
and fall of the death-rate 



the rise 



80 ORAL PATHOLOGY AND PRACTICE. 

abundantly demonstrated by the accompanying diagrams (see pages 
78 and 79), which represent the mortality of the city of Buffalo for 
three years. What is true of that city is true of all others, except 
as the tables for the different months may be a little modified by 
latitude. 

From November to May, in the northern temperate zone, 
the death-rate of children from diarrheas and other digestive 
disturbances is about the same with each month. With the latter 
month it begins to rise, shoots upward with an amazing increase 
during June, and reaches its highest point in July. In August 
it falls slightly, rises a trifle in September, and then falls as 
rapidly during that month and October as it rose in June and 
July, again reaching the low point in November, where it remains 
until the succeeding May. This is more or less true of all cities. 
Statistics show that the rule is general, but it is especially appli- 
cable to the poorer people, and the diarrheas and dysenteries are 
most fatal in the wards and districts in which they chiefly live. 

The diet of the average workingman's family is necessarily 
restricted in its character during the winter. In April may be 
seen by the wayside, and in the yards and in fields, his wife and 
children gathering the early herbs, dandelion, plantain, and others, 
to boil for greens. These form a welcome change of diet and are 
appetizing. What is grateful to their own palates, they argue, must 
be good for the baby, and it is fed from the family dish. Digestive 
disturbances commence, and they are intensified by giving it other 
early vegetables, and perhaps stale fruit. There is a period of 
incubation of the disease; it gradually increases in intensity, but 
death is not reached until the hot weather of July exacerbates the 
condition, and perhaps adds some kind of fermentative infection 
as the immediate cause of the death, the first degenerative step 
having been taken in the improper feeding of April cr May. 

The teeth have been erupting during this time, and the 
unreflective physician, if he is called in, will quiet the anxious 
parents and friends with the old plea of teething, perhaps lancing 
the gums when no tooth is near eruption, and neglecting the 
organs really at fault, until the sexton closes the scene by burying 
the fatal mistake beneath the churchyard turf. 



TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. 8l 

CHAPTER XIX. 
TREATMENT OF THE SO-CALLED DISEASES OF DENTITION, 

It is the first duty of the dentist or the oral physician, when 
he is called to examine the mouth of a child suffering from the 
imputed diseases of dentition, carefully to examine and see if 
there are any indications of disturbed dentition. A correct diag- 
nosis can only be made with certainty after a very careful con- 
sideration, not only of the child itself and the attending symptoms, 
but of its past history, its sanitary environments, and its diet. The 
age should be accurately determined, that it may be seen whether 
the dental development corresponds with that of the general 
system. This is important, because it is not infrequent that morbid 
conditions are ascribed to teething when the teeth due at the time 
are all in place. A medical journal reports a case of infantile palsy 
in a child more than three years of age, as due to teething. Both 
legs were cold and powerless. There was sufficient irritation of 
the gastrocnemius muscles to cause a permanent contraction, thus 
producing a kind of talipes equinus. Nothing is said about the 
state of forwardness of the dentition, but unless it was unusually 
delayed, the physician, as is too often done, jumped at his conclu- 
sions and ascribed to teething a trouble that must have had a 
deeper origin. 

The condition of the gums should be carefully noted. If they 
are normal, without any special inflammation or thickening, we 
should look elsewhere for the source of the irritation. It should- 
be remembered that the gum is naturally very hard and dense, from: 
the large amount of fibrous tissue in it. Normal growth, when 
the tooth is near the point of emergence, will find the gum whitish,, 
glistening, and tense in appearance. There may be such a condi- 
tion of impermeability, of toughness and hardness in the gum that 
the advancing tooth is retarded thereby, and hence undue pressure 
is brought to bear upon the, as yet, insufficiently protected pulp, 
thus inducing reflex nervous disturbances ; but unless there are 
either general or local disturbances that seriously interfere and re- 
quire immediate attention, the tooth easily makes its way through 
the gums, by their absorption under the slight but continual pres- 
sure induced by the developing roots which lift the crown. 

7 



82 ORAL PATHOLOGY AND PRACTICE. 

A clear distinction should, then, be made between those dis- 
eases which are, or even may be, the results of improper feeding, 
and the nervous disturbances caused by retarded or impeded denti- 
tion. Physicians are year by year more clearly recognizing this 
difference and governing their practice accordingly; yet by far too 
large a proportion of them still refer the diarrheas and fevers of 
childhood to teething, and make no special efforts to correct the 
vicious diet which may be the source of the disturbance. 

The treatment of the so-called diseases of dentition properly 
comes within the province of the medical man; yet so frequently 
are young children who suffer from bad feeding brought to the 
dentist for advice or gum-lancing, that some practical general 
directions may with propriety here be given. 

Fig. 15. 




Normal Appearance of the Upper Jaw at the Beginning of the Eruption of the 
Deciduous Teeth, showing Distention of the Bony Walls. (Tomes.) 

If the gums present their natural light pink, tense, hard, 
glistening appearance, it matters little whether there are or are 
not indications of an advancing tooth, the presumption is that there 
is another cause for the trouble. Retarded or disturbed dentition 
will usually leave an index upon the tissues about the point of irri- 
tation, and there will be found some departure from the normal ap- 
pearance. There probably will bs local inflammation, turgidity, and 
tumefaction, with redness and soreness. In the absence of these, 
the diet should be very carefully looked after, hygienic conditions 
inquired into, and in case of any departure from that which is 
proper, the food should immediately be changed and correct sani- 
tary conditions established. 

If there is a simple diarrhea, of not long continuance, with 
little of pyrexia, or fever, a simple correction of the diet will 
probably be sufficient. If the mother shall have weaned the child, 



TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. 83 

or her milk is insufficient, some one of the peptonized foods 
should be substituted. There are so many of these, chiefly pro- 
prietary, that it is scarcely proper to recommend any one above 
the others. It should be something of a very simple nature, in 
which digestion has already been begun by partial peptonization, 
or the diastatic action of some proper digestive ferment. 

A mild cathartic may be needed, and this is sometimes the first 
necessity, that the stomach and intestines may be relieved of 
irritating material. Castor oil in doses of from one-half to one tea- 
spoonful may be given. This will especially be indicated if the 
stools are of a green appearance. If, as will probably be the 
case, there is an acid condition, the following may be prescribed: 

I£ — Castor oil, 

Calcined magnesia, of each equal parts. 
Sig. — Dose, half teaspoonful, to be repeated in three hours if necessary. 

Or the following: 

3 — Pulv. ipecac, gr. ss; 

Pulv. rhei, gr. ij ; 

Sodse bicarb., gr. xij. 

Fiat chart, xii. 
Sig. — One every four to six hours for a child of one year. 

If there are no special inflammatory symptoms, the following 
may be used for the purpose of checking the discharges : 

I£ — Tinct. opii, gtt. xvj ; 

Bismuthi subnit., 3ij; 

Mist, cretae, 5jss; 

Syr. simp., ojss. 

Sig. — Shake well, and give in teaspoonful doses every four hours. 

If spasms are imminent or present, the following may be used : 

5 — Potas. brom., gr. iij; 

Tinct. cantharidis, gtt. iij ; 

Spts. camphoras, gtt. x. 
Sig. — Repeat p. r. n. in water. 

In simple diarrhea, after an evacuation of the bowels, the 
following may be prescribed: 

I£ — Bismuthi salicylate 5j; 

Pulv. ipecac, et opii, gr. x; 

Pulv. aromat, ®j. 

Fiat chart, xii. 
Sig.— One powder every three or four hours for a child of one year. 



84 ORAL PATHOLOGY AND PRACTICE. 

If the stools contain mucus and blood and are jelly-like, the 
following may be given: 

ty — Hydrarg. bichloridi, gr. % ; 
Liq. potas. arsenitis, gtt. xxxij ; 
Syrupi rubi, 

Syrupi rhei, aa 5ij ; 

Listerine, adoij. 

Sig. — Fifteen to twenty drops every two hours. If there is much pain, 
add one-half dram of deodorized tinct. of opium to the mixture. 

If there is considerable fever, Dover's powder may be given 
in small doses of one to two grains, or potassium bromide in five- 
grain doses. Sponge baths with tepid water will be found useful, 
and in extreme cases alcohol may be added. 

But the change of diet, and the most careful sanitary precau- 
tions as to the cleanliness of the nursing-bottle, if such is used, 
and of all the surroundings of the child, will be the chief care of 
the physician. Lancing the gums, or other operative procedures, 
in these instances will not be found necessary and should not be 
advised. Usually the case will be put in the hands of a general 
practitioner, but the dentist should be competent to prescribe in his 
absence, or in an emergency. 



CHAPTER XX. 

THE REAL DISEASES OF DENTITION. 

The real disturbances of dentition are the pathological condi- 
tions accompanying the advent of the teeth, in contradistinction 
to those which arise from improper feeding. Both are sometimes 
of the most serious character, but their origin and the phenomena 
that they exhibit are quite different. Usually, with the eruption 
of the tooth, the superincumbent tissues are absorbed away, and 
give place to the erupting organ. It should be remembered that 
up to this time there has been no formation of alveolar process; 
the bony walls that envelop the germ are very thin and slight, 
and they are not closed over it. (See Figs. 15 and 16.) There is 
very little if any pressure, the fibrous gum tissue offering the only 
obstacle to advancement. In normal conditions this is readily 



THE REAL DISEASES OF DENTITION. 85 

absorbed, but there are instances in which, through some malforma- 
tion of the tooth or imperfection of its tissues, or perhaps because 
of local disturbances, considerable pressure is exerted upon the 
tooth pulp, which at this stage of growth forms the greater part of 
the contents of the crypt, and upon which the enamel and dentinal 
cap already formed is resting. 

In such instances the tissues will not be in their normal state, 
and will be predisposed to inflammatory conditions. The tooth 
pulp will be especially irritable, and will respond to comparatively 
feeble impressions. 

Fig. 16. 




Normal Appearance of the Lower Jaw at the Period of the Beginning of the 
Eruption of the Deciduous Teeth, showing the Distention of the Bony Walls 
and the Natural Apertures in the Jaw through which the Teeth are Thrust. 
Alveolar Process not yet Formed: Rami not fully Developed. (Tomes.) 

The pressure that may be exerted upon the susceptible pulp 
in such instances may cause serious complications, but these will 
necessarily be of a reflex nervous character. The irritation to the 
delicate pulp tissue will react upon other tissues, through their 
nerve connections, and various functions may be disturbed. A 
diarrhea may possibly be the consequence, but it will not resemble 
that produced by digestive disorders. The child will plainly show 
nervous irritation; it will suddenly wake from sleep, perhaps with 
a scream. There will be spasms of the facial muscles, and inter- 
vals of pain will be succeeded by entire relief. There will be 
alternate slavering and dryness of the oral cavity. If a diarrhea 
is at times present, it will probably be succeeded by constipation. 
The appetite will be exceedingly variable, and there will be 
present that peculiarly fretful condition that indicates nervous 
irritability. It will be afraid to bite upon anything whatever, and 



86 ORAL PATHOLOGY AND PRACTICE. 

will strenuously resist all attempts to touch the gums. This will 
be in marked contrast to the condition when, despite digestive 
disturbances, dentition is proceeding normally. The child then 
delights to bite upon some yielding substance, like the finger or a 
rubber ring. If now the mouth is examined the gums about the 
advancing tooth will probably be found swollen, red, and turgid, and 
exceedingly tender to the touch. The mucous membrane will 
have lost the pink, tense, and glistening appearance of health, 
and will plainly show its disturbed state. During examination 
the child will perhaps scream hysterically, and plainly indicate its 
exalted nervous excitement. 

When these symptoms and appearances are present, no time 
should be lost in extending surgical aid. In view of the consid- 
erations advanced in Chapter XVI, and the possibility of the more 
serious complications which may arise from reflex nervous dis- 
turbances of dental origin, the occurrence of these indications 
should be looked upon as of the gravest character, and the most 
exhaustive examination of the dental condition should be instituted. 
The general state of advancement of the teeth, in comparison 
especially with the development of other organs, should be at once 
needfully observed, and if any tooth is probably, or even possibly, 
due its condition should be accurately ascertained. Full and free 
lancing of the gums has so often brought relief as by magic that it 
should be resorted to even when not positively indicated. The 
mere wound, with the local loss of a small quantity of blood, has 
been known to bring instant relief when the most drastic medical 
remedies have entirely failed. 

Prompt and deep scarification over any advancing tooth should 
be made, to divide the swollen gums and disengage the tooth. 
A crucial incision is usually best, if it be a molar, while a longitudi- 
nal one may answer for an incisor. In either case it should be deep 
enough thoroughly to divide all the tissues over the tooth, and 
extensive enough to free it. If there is any overlapping oper- 
culum of bone, this should be divided, for it will be the greatest 
obstacle in the way of the tooth eruption. 

This will usually be sufficient to give immediate and entire 
relief. If the diagnosis of the condition was correct, and the 
incisions sufficient to disengage the whole tooth, the change that 
ensues will sometimes be fairly startling. It may be well to give 



DENTAL CARIES. 87 

a small dose of potassium bromide (two to five grains), or an enema 
of chloral hydrate (five to ten grains), in water, to quiet the 
nervous excitement anal induce sleep, but usually this will not 
be found necessary, the removal of the cause of irritation being 
sufficient. There may occur instances in which the child is in 
spasms, or in convulsions, and the administration of chloroform 
necessary for their control before surgical measures can be safely 
resorted to, in which case there should be no hesitation on the 
part of the operator. 

The instrument best adapted to the division of the tissues 
over advancing teeth is the curved and pointed bistoury. It would 
be difficult to devise a worse one than the ordinary double-edged 
ovoid lancet, which cannot be made to cut at its extreme point. 
Something that can, if necessary, be forced deep down into the 
tissues at its point, and then drawn toward the operator, is essential. 
A pushing force should never be resorted to, as control of the 
instrument cannot be maintained, and there is serious danger of 
wounding surrounding tissues by its employment. 



CHAPTER XXI. 
DENTAL CARIES. 



A popular impression has long existed that caries of the 
teeth is of modern origin, and that it is due to an artificial mode 
of life, to a departure from the laws of nature, and to factitious 
environments. It has been held that our early progenitors knew 
not the pains of toothache, and retained their dental organs to 
a late period of life. The application to these fanciful speculations 
of the facts evolved by actual observation has shown that this 
is an error, and that there is not now and there never has been 
a pathological condition so universal throughout animal life as 
is caries of the teeth, for it is by no means confined to man. There 
are few of our domestic animals in whose mouths careful exam- 
ination will not reveal some form of oral disease, and among them 
caries plays an important role. Nor is it confined to domestic 
animals; the author has in his possession many skulls illustrating 



88 



oral pathology and practice. 
Fig. 17. 





Caries in the Lower Animals. Teeth of a Baboon (Cynocephalus) from a Skull in 
the Possession of the Author. 

Unfortunately the cut shows but a small portion of the decay. There were but three sound 
teeth (lower incisors) in the whole denture. 



DENTAL CARIES. 



8 9 



this, among them being that of an old male gorilla, with extensive 
decay of the teeth, and also connecting alveolar and antral abscesses, 
with necrosis of the superior maxilla. 

No people have yet been found among either civilized or 
savage races in which dental caries was not prevalent. Even the 
most ancient had no immunity, and the skulls of Egyptian mum- 
mies, four thousand years old, exhibit the same decay that is 

Fig. 18. 




Dental Caries. Penetration of the Tubuli by Micro-Organisms. (Miller.) 
Early stage shown by differential staining, only the organisms themselves being apparent. 
Very highly magnified. 



observable to-day. Hence we are not dealing with a condition 
that depends upon recent degeneration when we attempt the 
consideration of the subject. It is as old as the human race, and 
has probably caused more of pain and distress to the human family 
than any other disease with which man is afflicted. 

It would naturally be expected that a condition so universal, 
so ancient in its origin, and so distressing in its results would 
have been carefully studied, and long sir.ce thoroughly compre- 
hended. The fact really is, that until within fifteen years almost 



90 



ORAL PATHOLOGY AND PRACTICE. 



nothing was known of the real etiology of caries, or of the changes 
it involved. Speculation there had been in abundance, and many 
ingenious theories had been evolved, none of which satisfied the 
existing conditions. It is within the memory of even compara- 
tively young practitioners, when at our dental associations and 
meetings the most contradictory hypotheses were advanced. It 
was declared to be the effect of an inflammatory process of the 
tooth tissues. It was attributed to mineral acids that dissolved out 
the calcic salts of the teeth. It was by some believed to be due 
to a perverted nutrition, whereby there was a breaking down 

Fig. 19. 




Dental Caries. Penetration of the Tubuli by Micro-organisms. (Mummery.) 



instead of a building up of tooth elements. It was claimed to be 
the effect of a lack of mineral elements in the food during the 
period of growth. It was urged that it is the effect of electrolytic 
currents generated in the mouth of sufficient electrical energy to 
decompose tooth substance. In fact, the etiology of caries was a 
common battle-ground on which the advocates of the different 
theories met for polemical disputation without the possibility of 
victory for either combatant through the positive establishment of 
any special hypothesis. 

With the comprehension of the true principles of fermenta- 
tion and the advance of bacteriological knowledge, light began 
to dawn on the dark places, until at last, by the exhaustive 



DENTAL CARIES. 



91 



researches of Prof. Dr. W. D. Miller, an American dentist resident 
in Berlin, the problem of the ages was finally solved, and the 
true nature of dental caries was determined. It was found that 
those who had described it as a decalcification through the action 
of an acid were partially correct, but greatly mistaken as to the 
source of the acid. The advocates of the vital hypothesis had a 
section of the truth, but not enough upon which to base a practice. 
Electrical action had nothing whatever to do with it. 

Miller demonstrated that dental caries is due to a number of 
factors, but the principal and basal one is the growth of oral 

bacteria. 

Fig. 20. 




Dental Caries. Enlargement of the Tubuli by the Action of Bacteria. (Miller.) 

It has been shown in a previous chapter that the mouth is 
especially adapted to the growth of micro-organisms. Here are 
found the proper temperature, the most fitting media, and the 
required moisture; the temperature is as evenly maintained as 
it can be in any incubator, while the proper soil for their prolifera- 
tion is always provided. The various foods, especially the 
starches, will by the action of the ferments of the mouth be 
changed into forms admirably adapted to the growth of the acid- 
forming bacteria. Of some of these Miller made cultivations, 
analyzing their by-products, and he found, as the result of the 
proliferation of some special organisms, lactic acid. Further obser- 
vation enabled him specifically to point out the exact method by 
which caries is produced, which is as follows : 



92 ORAL PATHOLOGY AND PRACTICE. 

In the sulcus of a tooth, or between two teeth, or in any pit 
or irregularity of its surface, food lodges. By the action of some 
ferment this is perhaps changed into a fermentable sugar. This 
forms a suitable medium for some of the bacteria, and it is perhaps 
at once infected with certain acid-producing fungi, which in their 
growth split up the fermentable sugar, building into their own sub- 
stance such elements as are necessary, and leaving the remainder to 
form new combinations, or by-products, one of which may be lactic 
acid. This acid, especially active in its nascent or formative condi- 
tion, attacks the teeth, dissolving out the calcic salts, and forming a 
depression in which more food lodges, to pass through the same 
changes and to be in turn decomposed by new colonies of bacteria, 
thus forming more acid to continue the destructive work. 

Fig. 21. 




Dental Caries. Cross-section showing Melting Down of the Intertubular 
Substance and the Formation of Minute Cavities through the Action of Micro- 
organisms. (Mummery.) 

The dissolving out of the calcareous parts of the tooth 
leaves behind the organic or living portion, which may pass 
through inflammatory or degenerative stages, finally to be de- 
stroyed by putrefactive organisms. This is the essential principle 
of Miller's discovery. The enamel once penetrated by the pro- 
ducts of the growth of the vegetable fungus, the progress of the 
disorganization is more rapid. 

The bacteria penetrate the dentinal tubuli (see Figs. 18 and 
19) ; the acid generated within them, through the action of the 



DENTAL CARIES. 



93 



micro-organisms, enlarges the tubules (see Figs. 20 and 21), melt- 
ing down two or more into one, thus forming minute chambers or 
cavities in the dentine (see Fig. 22), which ultimately are blended 
into a yet larger one, and thus decay proceeds. Microscopical ex- 
amination shows these small spaces to exist at a considerable dis- 
tance beyond that which is actually broken down, and to account 
for the friable, crumbling dentine beyond the margin of the cavity 
proper. 

Fig. 22. 






Dental Caries. The Formation of Minute Cavities through the Melting Down 
or Liquefaction of the Intertubular Substance. (Miller.) 

The area denominated by Miller "the zone of infected dentine" 
is that pervaded by the organism, but in which the dissolving out 
of the calcareous inorganic matter of the tooth has not yet fairly 
commenced. 

Yet farther into the structure of the tooth have penetrated the 
bacteria, filling the tubuli without having distended them. Xot 
infrequently a number of these distinct zones of infection or 
caries are seen in their different stages, and readily traced. They 
are all the result of tooth infection and tooth decalcification through 
the action of bacteria. 

Miller, having demonstrated the true nature of this disease 



94 ORAL PATHOLOGY AND PRACTICE. 

by analytical methods, next attempted a kind of synthesis, arriv- 
ing at the same result, thus by an independent process proving 
the correctness of his previous observations. Obtaining a pure 
culture of a bacillus of decay, he immersed an extracted tooth 
in a proper culture solution, and with the utmost solicitude keeping 
it in the proper condition and at the exact temperature, he infected 
it with the bacillus and produced true caries outside the mouth 
and so removed from all physiological or vital connections. He 
thus demonstrated that caries is not a vital process, and that the 
proliferation of the bacillus under proper conditions will produce it 
as readily outside the body as in it (see Fig. 23). 

It must, then, be accepted as finally proven that dental caries 
is the result of an infection, and a true germ-produced disease. 
It is essentially a septic condition, and its medicinal treatment 
must be antiseptic. All prophylaxis must be in this direction, 
and the general principles of Listerism are as applicable to caries 
as to the treatment of wounds. To proceed farther than this in 
the consideration of the etiology of dental caries would be outside 
the scope of this work. 



CHAPTER XXII. 
THE PATHOLOGY OF DENTAL CARIES. 

Physiologists, pathologists, and histologists are sometimes 
inclined to consider the teeth as organs isolated, dissociated from 
the rest of the body, and as of such dissimilar, diverse characteristics 
that their relation to other tissues is but a minor factor in their 
study. Dental practice has been too exclusively confined to the 
teeth themselves, reputable practitioners asserting openly that there 
is no need for the dentist to study general anatomy or physiology, 
and protesting against everything save the very narrowest and 
most restricted teaching in our colleges. Almost unconsciously 
the great body of practitioners have been led to think of the teeth 
as segregate organs. There are many of our number who, while 
claiming professional relationship, treat their vocation as exclu- 
sively mechanical, and unwittingly debase their own condition to 
that of a mere artisan. 

The teeth are true modifications of bone. The study of com- 
parative dental anatomy teaches through what gradations they 



THE PATHOLOGY OF DENTAL CARIES. 95 

have passed in their evolution ; very many of the intermediate steps 
are recorded in the oral or pharyngeal cavities, and even in the 
gastric regions, of animals now extant. In some instances mastica- 
tion is absolutely performed upon true bone, of modified structure, 
which, however, is soon lost if it is submitted to any rough usage. 
We sometimes marvel that the teeth decay as they do. Were they 
not markedly differentiated in structure from the bone of which 
they are only modifications, they would not last as long as they do. 

Fig. 23. 




Artificial Caries. Cross-section. Identical with Natural Caries. (Miller.) 

That the teeth are living organs, with a vital dependence upon 
other tissues, that they are intimately connected with the rest of 
the body, is readily indicated by the fact that they are nourished 
by the same blood supply and receive their innervation from the 
same nervous system with the other organs. It is true that they 
are the hardest, densest tissues of the body, but in this they differ 
comparatively little from true bone. They are made up of a 
living matrix, into which calcium salts have been incorporated 
to give to them consistence. They are developed from the same 
connective tissue elements with other analogous tissues. Com- 
ponentry they only differ from bone in having a little more of the 
calcic salts and a little less of the living matter, in this respect the 
several tissues of the teeth showing the same variations that are 



96 ORAL PATHOLOGY AND PRACTICE. 

observable in different kinds of bone. To illustrate this the follow- 
ing table is presented : 

Bone. Cementum. Dentine. Enamel. 

Animal matter 34-00 32.00 28.00 3.00 

Earthy matter 66.00 68.00 72.00 97.00 

100.00 100.00 100.00 100.00 

Calcium phosphate 51-04 56.73 62.00 85.00 

Calcium carbonate 11.30 7.22 5.50 8.00 

Calcium fluorid 2.00 1.63 2.00 3.20 

Magnesium phosphate 1.16 0.99 1.00 1.50 

Sodium salts 1.20 0.82 1.50 1.00 

This table gives but an average of the proportional constitu- 
ents of the tissues. It would be well if a careful study of it could 
be made by every dentist. It will be seen that the same elements 
enter into the composition of all the hard tissues. 

The essential variation of tooth tissue from true bone is that 
through the progressive modifications of cementum, dentine, and 
enamel there is a gradual loss in the proportion of animal or organic 
matter, and a proportionate increase in the earthy or inorganic. 
This is most manifest in the calcium phosphate, upon which the 
teeth mainly depend for their density and hardness; there is 
comparatively little variation in the relative amounts of calcium 
carbonate, magnesium phosphate, and the other salts. In bone 
the living matter is more than half as much as the inorganic, while 
in enamel it is but one-thirtieth. 

But it is not alone in its constituent elements that the modi- 
fications of tooth from bone are exemplified. In their physical 
structure the gradation is still more marked. In bone the most 
distinguishing feature of the nutritive apparatus is the Haversian 
canals, about which are arranged in concentric grouping the cells 
containing the living matter. These corpuscles, the lacunae, com- 
municate with each other and with their source of nutrition by 
minute canals, the canaliculi. Each regular arrangement or system 
of these communicating lacunae is called a lamella, and the nutritive 
currents are thus in relation with all the tissue cells through the 
canaliculi. (See Fig. 24.) 

The first modification, or differentiation, is found in the ce- 
mentum, which has all the distinguishing features of bone, if we 
except alone the lamellae. The lacunae are present, and the canal- 
iculi ; even the Haversian canals are sometimes found. Thev are 






THE PATHOLOGY OF DENTAL CARIES. 97 

not as constant as in true bone, but even in that they are not always 
present. The lamellar, concentric arrangement of the lacunae about 
the Haversian canals is alone lacking, and this is the case even 
when these vascular canals are found in the cementum. The pro- 
portion of animal and earthy matter has been but slightly changed, 
the variation between different bones being sometimes greater than 
that between bone and cementum. Cementum, then, essentially 
differs from bone only in the loss of the lamellar arrangement of 
the cells. (See Fig. 8.) 

Fig. 24. 




d- 

Transverse Section of Bone, showing Lamellar Arrangement of the Lacunae about 
the Nutritional Centers. 
a, Haversian canals, b, c, d, Lacunae with branching canaliculi. (Gray.) 

The next step in the differentiation is found in the dentine,, 
which has lost the lacunal corpuscles that distinguish cementum 
and bone. As these contain the greater proportion of the living 
matter, we naturally anticipate a considerable reduction in that 
element, and analyses show that it has but about four-fifths the 
amount found in bone, while the earthy salts are correspondingly 
increased. In its physical structure, then, dentine retains but the 
canaliculi of bone, and these appear in their analogues, the dentinal 
fibrillar Instead of being the channel of communication between 
the lacunar, as in bone and cementum, they serve to connect the 
pulp, the analogue of the medulla of bone, with the cementum and 
dentine, the dependence not being very apparent. As in bone and 

8 



■*- 



98 ORAL PATHOLOGY AND PRACTICE. 

cementum, they are the medium of nutrition to the interstitial parts 
and the parenchyma. Dentine, then, is bone modified in structure 
by the disappearance of the lacunae, as well as their arrangement 
into lamellae. (See Fig. 9.) 

Finally, enamel is developed, — the densest, hardest, heaviest 
tissue of the body. This is that which alone is exposed to attri- 
tion, and to the direct action of foreign substances. 

Bone, cementum, and dentine are normally protected from 
exposure. If the former is uncovered, even to the external air, the 
most serious consequences may follow. Cementum is a little, and 
dentine considerably more tolerant of submission to external influ- 
ences. But neither of them accepts it without a pathological 
protest. Enamel alone successfully withstands external contact, 
and even that is in better condition when in possession of its 
natural covering, cognate to the skin and mucous membrane, 
Nasmyth's membrane. 

The very circumstances under which enamel exists must 
demand a material modification of structure. Accordingly we 
find that not only the lacunae of bone and cementum are lost, but 
the canaliculi of bone, cementum, and dentine have disappeared, and 
the principal remnant of the living matter left is the microscopical 
septum between the enamel prisms. (See Fig. 10.) But it is not 
dead, inert matter. Three per cent, of its structure is animal, so 
that, tenuous as is the thread, it has yet a vital connection with the 
other living portions of the body. The necessities of its existence 
demand that it shall have but a very minute proportion of animal 
matter to protect it against the exposure and rough usage which it 
must receive, but still it is identical with bone in its constituent 
elements, though widely variant in their relative proportions. 

Enamel is bone deprived of the lacuna: and canaliadi, cut off 
from its genetic organ, without independent nutrition, but still re- 
taining a proportion of that animal matter without zvhich it would 
be something alien and foreign. 

It is from this standpoint that the tissues of the teeth arc 
properly considered. It is in their relation to other tissues, and as 
a part of the living organism, that they are to be studied. The 
teeth are not lifeless, passive, extraneous objects. They have 
their pathological degenerations that demand medicinal agents. 
Their treatment cannot properly be exclusively surgical or op- 



THE MEDICINAL TREATMENT OF DENTAL CARIES. 99 

erative. It is true that their nutrition is limited and sluggish, but 
it exists, .and must be considered. They are amenable to the same 
general laws with the rest of the body. They contain a large pro- 
portion of inorganic matter, but even That must be elaborated in 
the alembic of nature, — it cannot be taken ready-made ; the calcium 
phosphate that forms so great a part of their body is of organic 
origin, and was distilled by nature's process from the organic 
matter that alone can be used as food or built into the system.. 

Every tissue of the tooth, as is the case with all other tissues, 
is the product of growth, hence is truly organic, and the assimila- 
tive processes can no more accept for nutritive purposes such inor- 
ganic matter as crude calcium phosphate than it can utilize carpet 
tacks to give iron to the blood, or lucifer matches to furnish phos- 
phorus for the brain. Such preparations may act as medicines, to 
be excreted as received, but their administration for metabolic pur- 
poses is an utter absurdity. 

That an hereditary tendency may be a factor in the etiology 
of dental caries, no one will for a moment dispute. One may 
inherit a diathesis, a congenital atonicity or a lack of resistant 
power, but a bacillus is not received as a patrimony. Modern 
investigation proves that so many of our disorders are of infec- 
tious origin that the doctrine of heredity must be materially 
modified. It has been demonstrated by repeated experiment that 
there is less of difference in the structure of so-called good and bad 
teeth than has been usually imagined. ' This throws us more directly 
back upon the vis medicatrix natures for our cures, and places us 
in a more intimate relation than ever with the vital principle, the 
innate resistant power of the body, and directs our thoughts into 
new channels. Dental caries must be studied from the vital stand- 
point, and in this view we approach the subject. 



CHAPTER XXIII. 

THE MEDICINAL TREATMENT OF DENTAL CARIES. 

It having been demonstrated that caries of the teeth is chiefly 
due to the action of micro-organisms, it naturally follows that the 
remedies employed, aside from operative ones, — which it is not the 

L.ofC 



IOO ORAL PATHOLOGY AND PRACTICE. 

province of this work to consider, — must be mainly antiseptic. 
Were it possible completely to sterilize, and to keep sterilized, the 
oral cavity, there could be no decay. But this is impracticable, 
and even undesirable. The peptonizing action of many of the 
bacteria may be an important factor in digestion, hence it would not 
be wise, even if it were possible, to eliminate them. But of the 
advisability of at least limiting their action there can be no ques- 
tion. The putrefactive organisms certainly can have no> useful 
office in the mouth, and common cleanliness demands that their 
growth should, as far as possible, be prevented. 

Could the teeth and the oral tissues be kept entirely clean and 
free from food and other debris, caries would be so limited that it 
would be of little moment. A carefully polished surface does not 
retain detritus or debris. Unless there are depressions, or pits, or 
roughness, there is nothing to which particles of food can cling. 
It is evident, then, that the first prophylactic measure against caries 
is the careful polishing of the teeth. Every deposit upon them 
must be removed, every pit obliterated, and every rough surface 
made entirely smooth. This will be the work of the dentist, but 
the keeping of them in that state will depend upon the exertions of 
the individual himself. A set of natural teeth in a state of perfect 
cleanliness is a sight seldom vouchsafed to anyone. Quite as rare 
would be a patient, just from the chair of the dentist, whose oral 
cavity had been put in perfect order. The average practitioner 
neither recognizes nor attempts the cure of half the pathological 
conditions that exist in the mouths that he treats. He fills the 
most conspicuous cavities, removes deposits that actually obtrude 
themselves upon his notice, and ignores the rest. Nor is it neces- 
sarily his own fault in every instance, for patients sometimes might 
offer serious objections to expending the time and money necessary 
for the treatment of all diseased conditions and the putting of the 
mouth in complete order. 

There is, however, no excuse for failing to call the attention of 
decently clean people to minute sedimentary precipitations upon 
the teeth, depressions or erosions of their surfaces, and inflam- 
mations and irritations of the soft tissues about them. That which 
is neglected is mainly in the line of prophylactic treatment. Were 
dentists generally more faithful to duty, their practice would be 
widely extended, while the people would be greatly benefited. 



THE MEDICINAL TREATMENT OF DENTAL CARIES. IOI 

It is unnecessary to call the attention of the student or practi- 
tioner to the most approved methods of cleaning the teeth. That 
duty devolves upon the teachers of operative measures. But the 
proper medicinal agents may be adverted to, and their use recom- 
mended. In the performance of this task it is impossible entirely 
to forbear mention of proprietary remedies, whose employment, 
when others can be substituted for them, should be avoided; 
yet they are sometimes a convenience, and, when the formula is a 
public one, may be professionally prescribed. A convenient, effec- 
tive and unobjectionable antiseptic mouth-wash, consisting of a 
single simple remedy, is quite unknown. The most efficient 
germicides possess toxic or caustic properties that are sufficient to 
exclude them. The best antiseptics are liable to the same objec- 
tions, and we are thus forced back upon the essential oils, which 
must be combined with other things to make them most useful. 
Listerine, borine, borolyptol, and other combinations are proprie- 
tary preparations, and therefore objectionable on ethical grounds, 
for no physician has any right to make a prescription for a patient 
unless he is fully aware of its entire character and thoroughly con- 
versant with every drug in it. He is paid for the expert knowledge 
of which the patient is not possessed, and he betrays that patient's 
professional confidence if he does not exercise due intelligence. 
Hence proprietary and secret remedies have no place in this work, 
unless their complete working formulae shall have been submitted 
to and approved by the author. 

For antiseptic use in the mouth, lysol presents some advan- 
tages, and the following may be used with the tooth-brush : 
I£ — Lysol, 3ss; 

Aquae, §xvj. 

Carbolic acid is not palatable, and it possesses toxic properties 
that forbid its use in strong solutions. But it is excellent as an 
antiseptic, and the following formula may be found useful : 
3 — Carbolic acid crystals, 
Glycerol, 

Rose water, of each 2 ounces. 

Five to ten drops in a wineglass of water should be used as a 
gargle, or with the brush. 

Thymol is similar in its action to carbolic acid, while it is free 
from its disagreeable odor : 



102 _QRAL PATHOLOGY AND PRACTICE. 

I... ~ ., ^-Thymol, 4 grains; 

Benzoic acid, 45 " 

Eucalyptol, 180 " 

Water, 2 quarts. 

This should be used as a gargle, after cleaning the teeth. 

The following is recommended by Professor Miller as an anti- 
septic gargle and wash : 

3 — Thymol, 4 grains ; 

Benzoic acid, 45 " 

Eucalyptol, 3^ drams; 

Alcohol, 25 

Oil of wintergreen, 25 drops. 

Hydronaphthol has been employed as an antiseptic, but was 
formerly more used than it is at present. The following formula 
has been recommended for a mouth-wash : 
3J — Hydronaphthol, 3ij ; 

Tinct. calendulas, 3iv; 

Aquae dest, ad Bviij. 

Any of these may be used with the tooth-brush, or as a gargle 
after cleaning the teeth. 



CHAPTER XXIV. 
PULPITIS— INFLAMMATION OF THE DENTAL PULP. 

Save as it is modified by surrounding conditions, inflammation 
of the pulp does not differ from that of other analogous tissues. 
The initial processes are the same, and hence the remarks in the 
section on Inflammation are applicable to the condition now under 
consideration. When the subject of general inflammation is fully 
comprehended, then, and then only, can the phenomena presented 
in pulpitis be clearly understood. It is but necessary to consider 
the peculiar complications brought about by the environments 
of the dental pulp, and to make due allowance for them, when the 
whole matter becomes plain and lucid. These complexities arise 
from the fact that the tissue of the pulp is somewhat modified 
in structure, and at the same time is enclosed within unyielding, 
osseous walls, which in health form its sure protection and in 
disease its rigorous prison-house. 

Whether or not the dental pulp, in its healthy, normal condi- 
tion, is or is not sensitive to external impressions is a disputed 



PULPITIS INFLAMMATION OF THE DENTAL PULP. 



103 



question which cannot be satisfactorily answered, because if" it is 
responsive it is at once claimed that it is not in a normal condi- 
tion. Certain it is that an entirely healthy tooth gives no sentient 
signs of the presence of a living pulp. It is sometimes a difficult 
matter positively to diagnose a dead pulp from a healthy living 

Fig. 25. 



L.F. 




Illustrating thk Relations of the Pulp to the Dentine. 
CD. Formed, calcified dentine. l.D. Forming, uncalcified dentine. L. F. Dentinal fibrillar, 
fibers of Tomes, — processes from the odontoblasts. OJ. Odontoblast cells. P.C. Cells of the 
tooth pulp. (Burchard, after Rose and Gysi.) 

one in natural conditions. Both are equally unresponsive to 
ordinary thermal changes, and the enamel and dentine of each are 
equally insensitive. 

Those who have had occasion to drill into or excavate a tooth 
that is entirely without disturbance of the pulp tissue, know that 
the dentine is unresponsive, while the pulp may be, and often is, 
punctured without the knowledge of the patient. 



104 ORAL PATHOLOGY AND PRACTICE. 

But if the tooth shall have sustained an injury, if there is reces- 
sion at the gums, or if there shall have been any pain in the teeth 
whatever, indicating pulp complications, or even any pulp disturb- 
ance insufficient to produce pain, both dentine and pulp may be ex- 
quisitely sensitive. There are occasional instances in which caries 
has extended to the pulp tissue, but in which there never has been 
either pain or sensitiveness. This cannot be reasonably accounted 
for upon the theory of personal idiosyncrasy, for individual tem- 
perament will scarcely cover a departure from general physiological 
laws. There must be a good and sufficient reason for such an 
immunity. 

The bloodvessels of the pulp possess a modified structure, in 
that they are without the complete muscular coats of those found 
in most parts of the body. (See Fig. 7.) In this respect they 
resemble those of the brain, which also is a tissue protected by un- 
yielding, bony walls, analogous to those of the tooth. The nerves 
of the dental pulp are also modified, for while they are composed 
of nervous elements they lack the general structure of those of most 
other parts of the body, and they are without the usual sheaths. 
The connective tissue of the pulp is not especially modified in struc- 
ture, but it must be peculiarly so in function, through its excep- 
tional blood and nerve supply. These variations will be specially 
considered in the chapter devoted to the diseases of the peri- 
cementum. 

The dentine is without nerve supply, and yet when in an irri- 
table condition it becomes acutely responsive. Sensation can only 
be conveyed through the dental fibrillse, whose embryonal structure, 
containing all the elements of nerve tissue, becomes inordinately 
responsive in certain conditions. It is well established that forma- 
tive tissue, embryonic matter, may take on inflammatory conditions, 
and under such circumstances possess characteristics unknown to 
it when in a normal state. 

It might be reasonably inferred, then, that the sensitiveness of 
either dentine or tooth pulp may be the direct result of irritation, 
and the inceptive stage of an inflammatory process; that sensitive- 
ness of dentine is but the result of that abnormal, irritative, in- 
flamed condition ; that the peculiar phenomena presented are due to 
the modified blood and nerve supply, and that in its normal and 
healthy state it may be quite irresponsive to external impressions; 



PULPITIS INFLAMMATION OF THE DENTAL PULP. IO5 

that any special responsiveness of either of the tooth tissues to ex- 
ternal impressions is an indication of a pathological condition, and 
that in treatment this should always be kept in view. 

The pathological changes presented and the phenomena 
exhibited in inflammation of the tooth pulp will differ from the 
corresponding phenomena in most other tissues just so far as the 
structure of these latter is varied and their environments are modi- 
fied by the tissues with which they are in relation. The peculiari- 

Fig. 26. 




Congestion of the Bloodvessels of the Tooth Pulp of a Dog after 
the Application of Arsenous Acid. 

ties of the nerve supply will change the character of sensation, 
while the special vascular system will cause a variation in the 
phenomena presented in the earlier stages of inflammation, and 
materially modify diapedesis. Proceeding upon this hypothesis, it 
is not difficult to comprehend some things heretofore unintelligible 
in the pathology of the dental pulp, and to find indications that may 
ce a more complete guide in diagnosis and treatment. 

A specially sensitive tooth is one whose tissues are in an 
irritable condition, and this is either the initial step in, or a 



106 ORAL PATHOLOGY AND PRACTICE. 

positive stage of, an active inflammation. The irritant may be 
any one of a long list, and may have its origin either in some- 
organic change, in a mechanical injury, or in some pathological or 
diseased condition. Thus : 

1. Caries has perhaps invaded the tooth, and micro-organisms 
have penetrated the tubuli, becoming themselves the irritant, or 
exposing the deeper dentine and pulp to the irritating action and 
thermal changes of external agents. 

2. It may be that an inserted filling is this outward irritant. 

3. There may be recession of the protecting gum tissue at the 
cervical portion of the tooth. 

4. A traumatic injury, a blow, inordinate use, the attrition of 
mastication, or any mechanical violence may be the source. 

5. Structural changes within the tooth pulp, such as the forma- 
tion of calcific deposits, are a sufficient excitant. 

Whatever the possible cause, there will be a hyperemia or 
determination of blood to the irritated pulp tissue and an engorge- 
ment of its capillaries. Because of the absence of the usual arterial 
and venous coats, the blood channels at once yield to the pressure. 
There is not the normal vaso-motor system of nerves to control 
the resilience of the vascular system, and diapedesis, or the escape 
of the elements of the blood into the pulp tissue, is materially 
modified. It may not at once take place in the usual acceptance 
of the term, but a stage of active engorgement of the blood 
channels ensues. (See Fig. 26.) 

The dental pulp is without the full and complete chain of 
lymphatics of the absorbent system, because the modification of the 
blood supply in a measure makes it unnecessary. The compara- 
tively unrestrained yielding of the blood channels, and the retarda- 
tion of the infiltration of the pulp tissue, allow for a return to a 
physiological state, if once the irritation ceases, without the ne- 
cessity for the usual process of resolution through the activity of 
the lymphatics in relieving a hyperplastic condition. It follows, 
then, that the treatment of ordinary pulpitis, after the removal of 
the irritating cause, should be directed toward the relief of the 
congested condition, by deflecting in some manner the determin- 
ing blood current and allowing the engorged vessels to empty 
themselves. So long as the possibility for this exists, it is quite 
feasible to preserve the vitality of an inflamed pulp. 



TREATMENT OF INFLAMED DENTAL PULP. 10^ 

When the pathological condition shall have proceeded to the 
extravasation into the body of the tissue of inflammatory products, 
there are practically no lymphatics to take them up, and their re- 
moval is as impossible as is that of any great effusion in the brain. 
Pulp capping under such circumstances will be a hopeless proceed- 
ing, and the presence of any infiltrated or effused matter will contra- 
indicate it. The fact that some pulps become fully exposed and 
their investing tooth walls are broken down without either pain or 
special sensitiveness, may be accounted for through their never 
taking upon themselves real inflammatory conditions, because of a 
modification of nerve structure greater than that which is usual. 



CHAPTER XXV. 



TREATMENT OF INFLAMMATORY CONDITIONS OF THE 
DENTAL PULP. 

Usually, the first indication of irritation of the dental pulp 
is responsiveness to external impressions, manifested by a sensi- 
tiveness to thermal changes. Cold air or cold water cause pain of a 
sharp, lancinating character. Not infrequently the neck of the 
tooth, or any abraded surface, is also sensitive to an outward irri- 
tant, such as a metal tooth-pick or instrument. This indicates 
dentinal irritation. The responsiveness to thermal changes in- 
creases and becomes more persistent, until there is a distinct 
odontalgia or toothache. This pain will be rather paroxysmal, 
returning upon slight provocation and passing away in a few 
moments. It may be difficult for the patient to determine exactly 
which tooth is affected, because of its sympathetic nature and 
because it is distributed over a considerable territory. Suc- 
cessively isolating each tooth by the rubber-dam, and the applica- 
tion of alternate heat and cold, will, however, usually determine 
the matter. Sometimes there is a response to percussion, and a 
diagnosis may thus be reached. This earlier stage will be that 
of hyperemia, and the beginning of engorgement, or congestion. 
The exalted sensibility is due to the irritable condition of the 
nerve tissue. If relief is not obtained, the pain, with the exacerba- 
tion of the inflammatory condition, becomes more intense and 
continuous. With the increased engorgement, the pulp, which is 



I08 ORAL PATHOLOGY AND PRACTICE. 

held immovably within the bony tooth walls-, becomes intensely 
irritable, and the pain instead of continuing remittent becomes 
almost continuous. The lancinating flashes can no longer be dis- 
tinguished, but are so quick in succession as to be practically unin- 
termittent, and there is at the same time a deep, boring pressure 
felt, which indicates that the inflammation is passing or already has 
passed to its second stage, that of effusion, in which there is an 
oozing out of the elements of the blood into the tissues. 

Up to this point the vitality of the pulp may readily be pre- 
served, if active measures are taken for the relief of the inflam- 
matory condition. This stage once passed, and extravasation into 
the pulp tissue having taken place, the probabilities are largely 
against conservation. 

About this time the pain changes in character somewhat, and 
it is not of such a sharp, lancinating nature. It becomes more 
steady and less paroxysmal. There is a greater feeling of pres- 
sure, and it is more readily located. The pulsation, which up to 
this time is very distinct, now ceases. The congestion soon reaches 
its height, and entire stasis of the blood current in the pulp is immi- 
nent. Cold is no longer irritative and warmth grateful. The 
opposite condition ensues, and ice-water will relieve the pain, while 
any warm application exacerbates it. The suffering caused by the 
affected organ is intense, but the end is probably near at hand. 
With complete stasis sensation is gradually lost, the pain pro- 
gressively abates, neither cold nor heat aggravates, and the tooth 
is irresponsive to any ordinary irritant. The inflammatory process 
has run its destructive course, and the pulp is dead. This is the 
usual train of symptoms and the ordinary progress of the disease. 

The treatment in the earlier stages should be abortive. Every 
effort should be put forth to relieve the hyperemic condition and to 
restore a normal circulation. The first essential is to make a clear 
diagnosis of the case, by carefully considering all the symptoms. 
The exact stage of the disease should be determined if possible. 
This having been done, the next point will be tg remove the cause. 
If it is progressive caries, the cavity of decay should be carefully 
washed out, all debris removed, and an anodyne introduced. If 
.any foreign substance is the irritant, it must at once be eliminated. 
The tooth must be relieved of all labor of mastication and given 
entire rest. Counter-irritants, such as iodine and aconite, or capsi- 



TREATMENT OF INFLAMED DENTAL PULP. I<X> 

cum bags and plasters, are useful by promoting metastasis ; that is, 
a new focus of inflammation is created in an approximate territory, 
but which is upon the surface where it can be reached and where 
resolution may be anticipated. This has a tendency to divert the 
impending blood currents, and thus to relieve the threatened en- 
gorgement of the pulp. 

Hot pediluvia, or foot-baths, should be prescribed, preferably to 
be used at night before retiring. The water must be as hot as can 
well be borne, and these are to be continued for at least thirty 
minutes, for the purpose of equalizing the circulation and relieving 
the plethoric condition of the pulp. 

Saline cathartics are useful and may frequently be employed 
with good results. They reduce the blood tension, remove from the 
sanguinary fluid a portion of its watery constituent, and thus greatly 
diminish the stress. 

Diaphoretics are perhaps the most important of the general 
remedies. They not only extract a considerable amount of water 
from the system and from the blood current, but they act as general 
depurators, promoting healthy functional action and removing 
local obstructions. 

Anodynes are indicated and should especially be administered to 
nervous or irritable patients. They equalize nervous function and 
tend to restore the proper tone to the arteries and veins through 
the vaso-motor system, and to allay the general nervous excitability. 

Probably there never was a case of simple pulpitis that would 
not yield, temporarily at least, to the vesicant action of a powerful 
counter-irritant at the back of the neck, a foot-bath continued for 
thirty minutes, and twenty to forty grains of potassium bromide. 
Such drastic measures, however, are not often called for, and are 
inadvisable when milder means will suffice. 

Any of the preceding measures may be resorted to in cases 
in which there is no actual or threatened exposure of the pulp 
through progressive caries, or by accident. When there is a large 
cavity of decay, it must first of all be thoroughly opened up, and 
all debris and foreign substances removed as carefully and as 
completely as possible. It should next be washed out with tepid 
water in which a little salt has been dissolved, by gently injecting 
the stream from a mouth syringe. The cavity should be dried out, 
and a pledget of cotton dipped in oil of cloves, or dilute creosote, 



HO ORAL PATHOLOGY AND PRACTICE. 

or hamamelis inserted, this to be carefully sealed up without pres- 
sure, by means of gutta-percha or a pledget of cotton dipped in 
chloro-percha. A solution of sandarac in which to dip the cotton 
should not be employed, because it insecurely seals it and very soon 
•decomposes, leaving the cavity in a worse state than at first. It is 
also likely to encapsule the remedy, and thus to isolate it and 
preclude its action. 

If there is actual exposure of the pulp tissue, after the cavity 
of decay has been opened up and carefully cleaned and washed 
•out, the rubber-dam should be applied, the opening dried out by 
means of hot air, and the pulp and cavity walls sterilized by the 
application of mercuric chloride, solution i to 2000, or some other 
effective germicide. If there is considerable congestion, a pledget 
of cotton dipped in the following may be carefully placed over 
the point of exposure and sealed up: 

B — Plumbi acetatis, u gr. v; 

Tinct. opii, 3ss; 

Aquae, oij. 

This should be allowed to remain for some hours, when it may 
"be changed for a dressing of dilute oil of cloves, or of cassia. All 
pain will usually cease with the application of an anodyne. When 
more active measures are demanded, the following dressing may 
be applied after the sterilization: 

B— Atropinse sulph., gr. j ; 

Aquae dest, oj. 

If the pulp shall have been wounded and bleeding ensue, or 
if there is exudation of serum from the exposed pulp, it may be 
dressed with a solution of tinct. iodine and persulphate of iron 
in equal parts. Tinct. opii may sometimes be necessary for the 
purpose of soothing the disturbed tissue. The inflammation and 
congestion once relieved, the necessary operative measures for the 
further preservation of the tooth may be instituted. If there is 
no actual pulp exposure these may, if skillfully executed, be con- 
fidently relied upon to serve their full purpose. If, however, any 
portion of the pulp tissue is really uncovered, the prognosis will 
not be as favorable. In the earlier stages of inflammation, before 
there is any exudation from the bloodvessels of the pulp, the 
best results may be predicted. If there has been extravasation of 
-the contents of the blood channels into the body of the pulp absorp- 



PERICEMENTITIS. Ill 

lion cannot be expected, owing to the absence of lymphatics, and 
breaking down of the tissue or death of the pulp will result. 

The successive stages in degeneration may be tabulated thus : 

First Stage. Second Stage Third Stage. Fourth Stage. 

Symptoms Sensitiveness. Pain (cold ex- Pain (cold Insensibility. 

acerbates). relieves). 

Condition Irritation. Infiltration. Inflammation. Stasis. 

Pathology Hyperemia. Diapedesis. Congestion. Death. 

Prognosis Good. Doubtful. Bad. Hopeless. 

Stasis and death, as suggested by Dr. J. B. Willmott, may in 
some instances be partial in the third stage, while in other 
cases decomposition may have commenced in circumscribed areas 
and the change in the symptomatology may, at least in part, be due 
to the condensation of the putrefactive gases under the reduction 
of temperature. 

The different remedies in the several classes that will prove 
best adapted to dental practice may be summarized as follows : 

Food Laxatives. — Green and dried fruits, cracked wheat, oat- 
meal, etc. 

Medicinal Laxatives. — Seidlitz powder, castor oil (doses for 
adults of 4 to 8 drams, and for children I to 3 drams), lac. sulphur 
(J to 3 drams, in syrup or milk). 

Saline Cathartics. — Epsom salts (2 to 8 drams in carbonated 
water), citrate of magnesia (dose according to preparation). 

Diaphoretics. — Warmth and exercise, warm drinks. Dover's 
powder (5 grains, repeated if necessary), spirits of Mindererus 
(2 to 8 drams every two to four hours), sweet spirits of nitre (2 to 
4 drams frequently). 

Diuretics. — Diluent drinks, mineral waters, beef tea, whey, 
gruel, cream of tartar ( 1 to 4 drams combined with \ dram biborate 
•of soda), borax (20 to 40 grains). 

Anodynes. — Potassium bromide (5 to 20 grains), sulphate of 
morphin (■£ to \ grain), aromatic spirits of ammonia (10 to 60 
drops). 

CHAPTER XXVI. 

PERICEMENTITIS— INFLAMMATION OF THE PERIDENTAL 

MEMBRANE. 

Sometimes this affection is closely connected with inflamma- 
tions of the dental pulp, and it may be derived from mere con- 



112 



ORAL PATHOLOGY AND PRACTICE. 
Fig. 27. 



Enamel. 



Enamel. 



Cornua of Pulp 

Dentine 
Fibrous Gum Tissue 



Aberrant Bloodvessel. 



Nutrient Artery. 




Bifurcation or Branching 

of Pulp. 
Lateral Foramen. 



Principal Foraminal 
Opening. 



Nutrition of the Dental Pericementum and Pulp. 

The condition here represented, is that seen only in young persons. In later life the 
" aberrant" bloodvessels and some of the canals at the apex may be closed by the advancing 
calcification. The former are not constant but sometimes may be observed. Cementum is a 
modification of bone, and these vessels may have a genetic relation to Haversian canals. The 
cut is schematic and not according to scale. 



PERICEMENTITIS. 1 1 3 

tiguity or proximity of tissue. Usually, however, it arises quite 
independent of the other disorder, and indeed is more severe when 
the pulp has been devitalized, either by design or disease. 

The pericementum is an exceedingly vascular organ, and it 
has an abundant nerve supply. This is necessary to its proper 
functional action. It is a kind of placental organ which affords the 
pulp of the tooth its vascular and nervous supply. The text-books 
and preparations which represent the arteries and veins of the 
tooth pulp as passing out at a single foraminal opening, perforating 
the pericementum and traversing the tissues until they anastomose 
with some larger vessel of which they are branches, and which is 
not in relation with the tooth at all, cannot be accepted as repre- 
sentative of the actual condition. No bloodvessel can be directly 
traced beyond the investing pericemental membrane. (See Fig. 27.) 

Fig. 28. 




Tooth Extracted by Author for Replantation, with Minute Threads of Chloro- 
percha Forced through Dentine and Cementum in Filling the Root. 

The foraminal opening of the normal tooth root is not a single 
direct aperture, having its axis in line with that of the pulp, but, 
especially in early life, is a delta with a number of communicating 
orifices, which begin to diverge near the apical junction of the 
dentine and cementum, and with a kind of circular sweep reach 
the pericemental membrane, with whose bloodvessels the branches 
from the dental pulp anastomose. Indeed, in early life the ana- 
logues of Haversian canals are not infrequently found penetrating 
the cementum and dentine at different points along the periphery 
of the tooth root, and containing accessory bloodvessels for the 
further supply of the pulp. Later in life these are usually oblit- 
erated by the advancing calcification. That this is true, the clin- 
ical observation of almost any dentist of wide experience might 
establish. There are few such who have not seen the whole apex 

9 



H4 ORAL PATHOLOGY AND PRACTICE. 

of a tooth root denuded through some pathological process, or by 
surgical operations, without interference with the vitality of the 
pulp. Many have known instances in which, through diseased 
action or by accident, one side of the root of an anterior tooth, 
with the whole of the apex, was completely denuded without any 
devitalization of the pulp. When this tissue has been restored by 
functional activity, the tooth was found as responsive to thermal 
changes as ever. The author has frequently had occasion to 
remove all the investing osseous tissue from a tooth root, save 
perhaps a comparatively small portion at one side, and that without 
final prejudice to its vitality. In some of these instances there 

Fig. 29. 



Tooth with Hypertrophied Pericementum showing Blood Supply. 

Microscopical section demonstrated that nutrient arteries of considerable size entered at 
a and b and were distributed to the pericementum. (From a specimen furnished the author 
by Dr. D. E. Kulp.) 

could have been no vascular supply to the pulp, unless it was 
through some kind of Haversian canal penetrating the cementum 
and dentine upon a lateral aspect. The author has frequently 
demonstrated the presence of something of this kind in freshly 
extracted young teeth. (See Fig. 28.) 

It is well known to oral surgeons that resection of the inferior 
dental canal, with entire obliteration of the inferior dental artery 
and nerve, does not in any way interfere with the vitality of the 
lower teeth, which the text-books frequently represent as receiving 
their vascular and nervous supply from that source. These con- 
siderations should materially modify our views of the pathology of 
the dental pericementum, and change some previous conceptions of 



PERICEMENTITIS. 115 

its function and susceptibility to diseased action. In the light of 
these views, much that was before incomprehensible becomes plain 
and intelligible. We can understand why and how it is that the 
blood and nerve supply of the tooth is modified, and how it arises 
that the vessels of both are without the usual external muscular 
coats, and approach those of the brain in character. 

Having the important and compound functions of affording 
the pulp of the tooth its nerve and blood supply and giving nutri- 
tion to the cementum and bone, and being in close relation with 
the gum tissue, the pericementum is very likely to take upon itself 
a pathological condition. Continued irritation of a mild character 
may result in a hyperplasia of the membrane, with an enlargement 
of the principal nutrient arteries and a generally congested irrita- 
tive condition. (See Fig. 29.) It serves as a cushion to break the 
force exerted upon the tooth in occlusion, or from a blow, or any 
other external violence. Hence it is liable to injuries and acci- 
dents. It is also very subject to infection by micro-organisms 
from a decomposing tooth pulp. This last is without doubt the 
most fruitful source of inflammatory conditions, and such instances 
are constantly falling under the notice of the dentist and oral 
physician. Another common cause is the bad occlusion or absence 
of some of the teeth, which throws upon a few the work of many. 
Teeth used as anchorages for bridges of an extensive kind are 
peculiarly liable to and are often lost by pericemental irritation 
caused by overwork. 

Many practitioners have no clear conception of the difference 
between pericementitis and pulpitis, inasmuch as each produces 
a distinct odontalgia or toothache which only close observation 
will distinguish from the other. And yet the two conditions have 
little in common except the pain, and that is not of the same 
character. It may be well to compare their pronounced symp- 
toms as an aid in diagnosis. 

Pulp itis. Pericementitis. 

The pain is of a sharp, lancinating The pain is dull, steady, boring, 

character, and in its earlier stages it throbbing in its character, and is not 

is distinctly paroxysmal. at all paroxysmal. 

The tooth is exquisitely sensitive There is no sensation to changes of 

to thermal changes; in its inceptive temperature, and neither cold nor 

state cold, and in its later condition hot applications materially affect it. 
heat, exacerbating the pain. 



Il6 ORAL PATHOLOGY AND PRACTICE. 

Pulpitis (cont.). Pericementitis {cont.). 

There is no swelling of the tissue The tooth becomes exceedingly 

about the tooth, and no tenderness to sore, and the least pressure upon it 

pressure in ordinary cases, unless the causes pain. In the later stages 

pulp shall in some way be exposed. swelling is common. 

It is at times quite difficult to de- There is no trouble in deciding 

termine exactly which tooth is af- which tooth is the diseased one, the 

fected, the pain being fleeting in its pain being steady in degree and in 

nature, and inducing reflex symptoms [position, and the soreness readily 

in other teeth and tissues. locating it. 

The pain is apt to be worse upon The pain remains nearly constant 

going to bed, and excitement and without much reference to external 

fatigue increase it. conditions or circumstances. 

It is possible to bite upon the tooth The tooth is very sore to the 

without any special sensation, and to touch, any occlusion in mastication 

use it in mastication, if thermal ex- or ordinary shutting of the mouth 

tremes be avoided. giving pain, irrespective of thermal 

changes. 

The tooth is not elongated, nor The tooth is raised in its socket, 

does it strike first in occlusion. and strikes before any of the others 

occlude. 

Treatment of Pericementitis. 

The first care should be to give the offending tooth rest, by 
preventing its occlusion. This may be done by placing gutta- 
percha caps over other teeth, to prevent the striking of this. The 
cause should be determined, and if possible removed. If it be 
infection from a dead pulp, the chamber should be carefully 
cleaned and sterilized, and an anodyne applied in the root channel, 
caution being exercised to avoid forcing septic matter through the 
foraminal openings. It may be advisable to seal up in it some of 
the essential oils, properly diluted, such as cassia or cloves, as an 
antiseptic. A counter-irritant should be applied over the apex of 
the affected tooth, for the same reason that it is used in pulpitis, 
and it is even more likely to be effectual. The same general 
remedies may be employed, such as saline cathartics, diaphoretics 
and nervous sedatives. Refrigerants are useful, and lumps of ice 
wrapped in muslin may be placed between the lip and the tooth. 

If these are not effectual, resolution may sometimes be in- 
duced by hot fomentation upon the face and neck. Prof. C. N. 
Johnson recommends that water as hot as can be borne be directed 
upon the part, with some force, for twenty or thirty minutes, to 



ALVEOLAR ABSCESS. , Iiy 

promote resolution. An acute pericementitis has also been 
readily aborted by the precisely opposite treatment of directing 
an ether or rhigolene spray upon the part until it has become 
bloodless. Both are useful, but are best adapted to different 
stages of the disease. If infection is present Prof. A. W. Harlan 
recommends the administration of one-tenth of a grain of calcium 
sulphide every ten minutes for an hour, the interval then to be grad- 
ually increased. If there is a great degree of pain, the following 
may be administered: 

3 — Acetanilid., gr. viij; 

Syr. simp., 3ij; 

Spts. frumenti, 3ij. 

Sig. — One-half at 6 p.m., the remainder two hours later. 

The patient should be given a hot foot-bath, placed in bed 
and kept warm. If the inflammation is exceedingly acute, scari- 
fication of the gums about the affected tooth may be resorted to. 
If there is great tension of the tissue, a bharp-pointed scalpel or 
bistoury may be used to cut through the gum tissue over the 
apex of the tooth, a little cocain having been previously applied, 
or the point of the instrument dipped in pure carbolic acid and 
applied to the surface until it has become white, when it may be 
forced through the alveolar walls until the seat of inflammation 
is reached, thus removing the tension and giving immediate relief. 



CHAPTER XXVII. 
ALVEOLAR ABSCESS. 

An Abscess is the formation of pus somewhere within the body, 
as the result of some local or circumscribed inflammation. An 
Alveolar Abscess is an infective inflammation within the alveolar 
walls. It may be the result of some foreign substance acting as 
an irritant, or some injury may have been the exciting cause. 
Either of these agencies may result in an inflammation so violent 
as to induce a breaking down of tissue, and infection with sup- 
purative organisms will induce the formation of pus, which 
reaches the surface by the route presenting the least resistance. 
An alveolar abscess does not, therefore, necessarily presuppose the 
death of the pulp. If the inflammation does not materially affect 



n8 



ORAL PATHOLOGY AND PRACTICE. 



that tissue, or if the pericementum involved does not include that 
from which the blood supply of the tooth is derived, an alveolar 
abscess may be established without pulp devitalization. 

The terms "abscess" and "ulcer" are frequently confounded. 
Even dentists of intelligence speak of an "ulcerated tooth," when 
practically such a thing is an absurdity. An abscess and an ulcer 
have little in common. The primary cause of the first is infection 
by some pyogenic organism, which necessarily has no part in in- 
ducing an ulcer. An abscess always forms in some cavity within 
the body : an ulcer always has its inception on an external cutaneous 
surface. An abscess is a circumscribed collection of pus : that is 

Fig. 30. 




Pericemental Abscess which in No Way Involves the Vitality of the 
Tooth Pulp. (E. C Kirk.) 

not at all true of an ulcer. The one makes progress from within 
outward : the other just the reverse. The one tends toward resolu- 
tion : the other is progressively degenerative. An abscess is always 
the result of a recent lesion : an ulcer is never connected with a fresh 
wound or infection, but has its inception in some old injury or 
morbid structural change. It would be difficult to instance a 
grosser misuse of technical terms than the calling of an alveolar 
abscess an "ulcerated tooth." 

Professor Kirk has demonstrated that a pericemental abscess 
may develop in the parenchyma of the membrane ; that is, it may be 



ALVEOLAR ABSCESS. 



II 9 



neither supra- nor infra-, but intra-pericemental. (See Figs. 30 
and 31.) It is indeed probable that such abscesses are more fre- 
quent than is usually supposed. Most practitioners of experience 
have at some time in their lives drilled into an abscessed tooth and 
found a living pulp, which would demonstrate that the lesion was 
not at the foraminal apex. By the study of these conditions Pro- 

Fig. 31. 




Transverse Section across Buccal Roots of Fig. 30, showing the Abscess-cavity 
to be between the pericemental walls. 

a, a. Hypercementosis. b. Thickened pericementum covering root. b x . Thickened peri- 
cementum forming external wall of abscess-cavity, c. Abscess-cavity occupying central por- 
tion of divided pericemental membrane, d. Section through fistulous outlet of abscess. (Kirk.) 

fessor Kirk believes he has found a common factor of infection to 
be the diplococcus of pneumonia, or the pneumococcus of Fried- 
lander, with occasionally staphylococcus pyogenes aureus as a con- 
comitant. 



120 



ORAL PATHOLOGY AND PRACTICE. 



But such a condition is not that which has usually been denomi- 
nated alveolar abscess. The common acceptation of the term is that 
affection which is the result of inflammation and death of the 
pulp, its infection, and the consequent inflammation and infection 
of the pericementum from contiguity of tissue. If we take up 
the subject of the last chapter at the point of its closure, and 
suppose the pulp of a tooth to be devitalized as the result of stasis 
of the blood currents, with the consequent stoppage of all nutrition 
through a distinctive inflammation, the next inquiry will be 
concerning the final disposition of the devitalized pulp. 

Fig. 32. 




Metastatic Abscess. 

Mass of staphylococci in the center, surrounded by an area of coagulation necrosis, the 
whole inclosed by a cordon of leucocytes. (Kirk.) 

If there is no source through which it can become infected 
with micro-organisms, it will probably become mummified and 
desiccated; the moisture will be absorbed from it, and it will 
assume the condition of dry gangrene, in which it will remain for 
an indefinite period without being the cause of any irritation what- 
ever. 

If, however, such a pulp chamber be opened without the 
strictest antiseptic precautions, perhaps years after the death of 



ALVEOLAR ABSCESS. 



121 



its contents, germs of infection may be carried in upon the non- 
sterilized instruments or admitted with a particle of saliva, and 
septic inflammation, with perhaps consequent alvoolar abscess, will 
be the result. 

The infection may arise from either one of two sources. If 
there is a cavity in the tooth that penetrates to the neighborhood 
of the pulp, the bacteria may there find entrance, and decomposing 
the pulp tissue by putrefaction they may cause the formation of 
offensive gases, which forcing their way through the foraminal 
openings will act as an irritant upon the pericementum, and 
induce an acute inflammation of that tissue. 



Fig. 33. 




Blind Abscess at the Root of an Upper Incisor. 
a, Abscess cavity in the bone, b, Drill hole exposing the pulp chamber for drainage. 
(Burchard, after Black.) 

If there is no special cavity of decay in the tooth containing 
the recently devitalized pulp through which infective organisms 
may find entrance, it may still become contaminated from some 
other center of infection that may exist in the body. The bacteria 
may be transported by the blood or through the lymph tracts, or 
may in some other manner be carried within the body to the dead 
tissue, and in this manner form a source of contagion. By what- 
ever method the pulp becomes inoculated with putrefactive or sup- 
purative organisms, whether from external sources or by auto- 
infection, the result will be the same, — the formation of suppurative 
products and the infection of the pericementum and other tissues 
in the neighborhood of the foraminal openings. Pus will thus be 
formed and an abscess established (see Fig. 33). 

Incipient Alveolar Abscess is the term applied to the condition 



122 ORAL PATHOLOGY AND PRACTICE. 

that has existed up to this point. It simply implies the earlier 
stages of the destructive inflammation, before pus shall be actually 
present, during which period it may be possible to abort the abscess, 
or prevent the breaking down of tissue. 

A Blind Abscess is one in which there is a cavity of decay com- 
municating with the pulp chamber, and in which it is possible for the 
pus to be drained through the pulp canal. 

A Discharging Abscess is that condition in which the pus forces 
its way to the surface through the alveolar walls and establishes a 
fistulous opening. 

The formation of an alveolar abscess depends upon infection 
by septic organisms. These are always a source of irritation, and 

Fig. 34. 




Infected Exudate about the Apices of the Roots of a Molar Tooth in a Case of 
Subacute Pericementitis. 

The center of the mass consists of pus and broken-down tissue; the superficial portion is 
the desiccated exudate not yet decomposed. 

induce inflammatory conditions. The pericementum about the 
foraminal opening of the root of a tooth being thus affected, there 
will ensue under the stress of the inflammatory conditions the 
phenomena described in the chapter (VI.) on General Inflamma- 
tion. There will be changes in the bloodvessels of the vascular 
tissues that will finally result in diapedesis, or the pouring out of the 
plastic lymph. This will be infected by the organisms, and in- 
stead of being either removed by resolution or built up by regular 
progressive metamorphosis, it will be broken down. The leuco- 
cytes, or white blood corpuscles that have thronged to the irritated 
neighborhood, will lose their vitality through the irritation and 
infection, and assume the character of pus corpuscles; the invest- 
ing tissue will be broken down and decomposed, thus forming a 



ALVEOLAR ABSCESS. I2J 

cavity about the foraminal opening; the water of the tissue and 
the serum of the blood will mingle with these, and the whole mass 
will be that fluid that forms the contents of the abscess cavity. 

If, now, an opening be drilled to the pulp chamber this septic 
matter may be discharged through the pulp canal and a blind 
abscess will be the result. (See Fig. 33.) If there is no surgical 
interference the pus will make its own way to the surface by the 
line of least resistance, and there form a fistulous opening. 

There may be about the periphery of this pus cavity, when so 
formed through the breaking down of the tissue, a partial attempt 
on the part of nature to build the exudate into new tissue. It may 
possess a kind of consistence, and this partially organized, partially 
desiccated plastic lymph will form a line of demarkation that will 
inclose the disturbed territory. (See Fig. 34.) Upon its external 
surface it will exhibit the characteristics described, but its center 
will be a collection of pus and disorganized lymph. If the tooth 
is now extracted, this mass may be found clinging to the root, the 
size of an ordinary pea, and when so removed with a deciduous 
tooth it has been mistaken by the unintelligent for the germ of a 
permanent tooth. It is only the plastic exudate that filled the cavity 
produced by the breaking down of the tissue, whose surface is 
desiccated or dried, while its interior is completely broken down. 

The infected point may not be at the foraminal apex of the 
tooth, but may be at some point upon the side of the root, or between 
them at their point of divergence. 

The fact that the blood and nerve supply of the dental pulp 
are derived from the pericementum, and that channels analogous 
to the Haversian canals of bone may in comparatively young 
persons communicate with the pulp through the cementum and 
dentine at almost any point, naturally introduces another complica- 
tion in the proper treatment of so-called dead teeth. Not infre- 
quently is an exceedingly sensitive point found somewhere along 
its course when a broach is passed into the pulp canal of a devital- 
ized tooth, and it may be that the oozing of blood and serum 
from such a point, even after the foramen has been stopped, will 
give great annoyance. This may be the mouth of one of these 
communicating blood channels, and it is easy to comprehend that 
the pericementum at the point at which this is given off may 
readily become infected from a septic canal, and thus form a focus 



124 



ORAL PATHOLOGY AND PRACTICE. 



of inflammation and disorganization quite distinct from that about 
the usual foraminal opening. The latter may be thoroughly 
drained and completely sterilized without beneficial result, because 
it is reinfected from another opening in the pulp canal as fast as 
it is rendered aseptic. In teeth having more than one root these 
collateral vascular branches are sometimes given off from the peri- 
cementum at the bifurcation, and at these points may be established 
a focus of infection and inflammation which it is difficult thor- 
oughly to drain, and impossible entirely to disinfect and sterilize. 

Pus having once formed at any point about the periphery of 
a tooth, it becomes necessary for it to be evacuated, as it is essen- 
tially a foreign body possessing peculiarly irritating properties. 




Alveolar Abscess at. the Root of a Superior Incisor Discharging into the 
Anterior Nasal Fossa. 

a, Very large abscess cavity in the bone, b, Fistulous opening in the nasal cavity, c, 
Lip. d, Tooth. (Black.) 

It usually secures egress through the breaking down of the tissue 
that encompasses it. The pressure of the gases of putrefaction that 
are evolved, with that of the constantly increasing pus, causes 
resorption of the investing bone, while the inflammation and 
infection induce progressive decomposition, and thus an opening 
is made to the surface, the pus is evacuated and the acute symp- 
toms pass away. 

If no remedial measures are instituted, the sinus perhaps then 
closes up and the patient may fancy that a cure is established. 
But the pericementum at the infected point, and the tissues about 
it immediately involved, remain in a septic condition, and the 



ALVEOLAR ABSCESS. 



125 



efforts of nature to restore a true physiological condition are made 
futile by constant reinfection. An acute inflammatory stage 
again ensues, the plastic exudate is once more poured out, only 
to be reinfected, with a fresh breaking down into pus. The 
abscess ''gathers" again, but this time, as the old sinus will not 
have been completely obliterated, there will be less resistance, and 
the pus will with decreased difficulty reach the surface. This 
process may be periodically repeated until a complete and con- 

Fig. 36. 




Chronic Alveolar Abscess with Fistula Discharging under the Chin. 

The pus burrows through the soft tissue beneath the periosteum until it reaches the point 
of exit, a, Abscess cavity in the bone. b, b, b, Course of fistula, c, Lower lip. d, Inferior 
incisor. (Black.) 

tinually patulous sinus shall have been formed, when all acute 
symptoms disappear and a chronic abscess is established, through 
the disorganization of the nutritive currents and the continuous 
effusion and uninterrupted infection and breaking down that ensue. 
This condition may persist until a cavity of considerable extent 
has been formed in the alveolus, or even in the body of the bone. 
The course of the pus in reaching the surface in the usual 



126 



ORAL PATHOLOGY AND PRACTICE. 



forms of alveolar abscess is directly through, the thin alveolar walls. 

This is the shortest route, and the one that ordinarily presents the 
least resistance. But although the tendency of the pus is toward 
the nearest point of exit, the external plates of the bone are usually 
compact tissue, while the interior is cancellous. Because of this 
fact the burrowing may be through the less dense portions of the 
hone and away from the usual course. 

Fig. 37. 




Separation of the Periosteum from the Bone by the Burrowing of Pus from 

an Alveolar Abscess. 
a, Abscess, b, Pus pocket beneath periosteum. c,Lowerlip. d, An inferior tooth, e, Tongue. 
(Burchard, after Black.) 

The pus may find some cavity of the body and be discharged 
into the posterior or anterior nares, or into the maxillary sinus. 

In such instances the diagnosis may be extremely difficult. Many 
cases are on record in which treatment had for a long time without 
avail been directed toward complications which did not exist in 
reality until a more careful examination revealed a dead tooth as 
the source of all the trouble. (See Fig. 35.) 

Sometimes the pus will penetrate the alveolar walls, and, en- 
countering the fascia of a muscle, follow along its course until it 



ALVEOLAR ABSCESS. 1 27 

reaches a point considerably distant before it finally finds the sur- 
face. A discharging abscess under the chin, the direct result of a 
devitalized inferior incisor tooth, has often puzzled the medical 
man, who never once thought that the dentist might give quick 
relief. (See Fig. 36.) Pus has been known to burrow along the 
fibers of the platysma myoides muscles until it has reached the clavi- 
cle, or, penetrating the cervical fascia, finally strike the omo-hyoid 
and follow its course until it emerged at the point of the scapula. 

In some instances of rather indolent abscess, the pus makes its 
way through the alveolar walls until it reaches the periosteum of 
the bone, which it detaches, and spreading out beneath it completely 
cuts oft 7 all periosteal nutrition. (See Fig. 37.) This is a condition 
which, if not relieved, may result in osseous necrosis. It may be 

Fig. 38. 




Alveolar Abscess. 

a, Primary abscess pocket. &, Secondary pocket caused by the infiltration of septic matter 
through the cancellous bone tissue. 

observed more frequently in the vault of the mouth, when the pus 
has penetrated the palatal process of the superior maxillary. The 
tough, fibrous character of the tissue immediately beneath the 
mucous membrane of the roof of the oral cavity presenting a great 
obstacle to the course of the pus, it not infrequently spreads over 
a considerable portion of one side of the vault. 

There are cases in which the pus burrows to some distance in 
the alveolus, establishing separate pockets which become distinct 
points of infection. (See Fig. 38.) In one such instance, from an 
infected point at the apex of a superior cuspid, which had a dis- 
charging sinus between that and the point of the lateral incisor, and 



128 ORAL PATHOLOGY AND PRACTICE. 

which persistent treatment failed to cure, a secondary sinus was- 
finally traced back to a point between the first and second premolars, 
or bicuspids, where was a second focus of infection, and from this 
another led yet farther, back of the roots of the second bicuspid, 
where there was a third pus chamber. It was not until all these 
were explored and sterilized that anything approaching a cure 
could be obtained. 

These secondary pockets, or foci of infection, whether upon 
the periphery of the tooth as the result of a former collateral 
blood supply to the pulp, or existing as pockets within the alveolus 
in consequence of the burrowing of pus back into the bone, are 
especially perplexing to the practitioner, because he never knows 
when to expect them, and he has no early means of diagnosing 
the exact location of the seat of the trouble. After the proper dis- 
infecting and sterilizing process has been resorted to in vain, it 
may be suspected that there are somewhere foci of infection that 
have not yet been reached by the remedies used. The continuation 
of the discharge of septic or sanious matter indicates that disinfec- 
tion and antisepsis are not complete, and no entire cure may, under 
such conditions, be expected. 



CHAPTER XXVIII. 



SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR 

ABSCESS. 

The objective as well as the subjective symptoms of Alveolar 
Abscess are sufficiently pronounced to prevent any mistake in 
diagnosis. That which is under special consideration, the result 
of the infection of the contents of a pulp chamber or canal, begins 
with a pericementitis that gradually increases in severity. The 
soreness is extreme; the tooth is materially lifted in its socket and 
becomes loose, with that peculiar feeling of non-support that 
indicates fluid at the extremity. This is the extravasated lymph 
and serum. Within a few hours there is the distinct febrile condi- 
tion, with its elevation of temperature, quickened pulse and suc- 
ceeding rigor — the septic fever that invariably indicates the forma- 
tion of pus and which is idiopathic. The red line or red blotches 
that are characteristic of pericemental inflammation, and which 
are peculiarly observable up to this point, now begin to fade away 



SYMPTOMATOLOGY AXD TREATMENT OF ALVEOLAR ABSCESS. 120, 

or to be succeeded by a deep red that is continuous with that of the 
neighboring tissues, and there is, in very acute cases, a tumor or 
distention of the alveolar walls. The pain, which is deep-seated, 
continuous, and of a boring character, is now intense, but there is 
little swelling of the soft tissues. 

The pus is burrowing its way toward the surface of the bone, 
and the pressure exerted by the confined matter is the source of the 
suffering. This continues until the alveolar walls have been pene- 
trated, and the pus escapes into the soft tissues. Great swelling 
now ensues, with subsidence of the pain, consequent on the escape 
of the confined fluid into the tissues that can yield to the pressure. 
Sometimes the infiltration of the tissues and diffused cellulitis 
are so great as to close the eye and greatly distort the face. But, 
although the appearance at this stage is much more serious and 
alarming that at previous ones, the pain and soreness are very 
much less, and the tension is relieved. Finally, there is "pointing," 
fluctuation may be distinctly detected beneath the finger, and the 
abscess is ready for the lancet. 

The general indications of a septic condition, the infection by 
pyogenic organisms, and the formation of pus, will be as follows: 

1. Anorexia, or loss of appetite and general tone. 

2. Chills or rigors, which are more or less pronounced. 

3. Headaches, sharp, persistent, and blinding. 
4.. Fever of a distinct type, — the septic fever. 

5. Tongue coated and covered with dark-colored fur. 

6. Constipation, persistent, but without special pain. 

7. Urine scanty, of high color and specific gravity. 

8. Nervous disturbance, which constantly increases. 

The latter symptom may be more or less apparent, depending 
upon the gravity and severity of the attack. In slight cases, like 
ordinary alveolar abscess, it may amount to nothing more than 
uneasy restlessness, while in general septic conditions there may be 
violent delirium. The appearance of these symptoms marks what 
is called "septic-" or "auto-intoxication," or period of functional 
excitement produced by the absorption of septic or poisonous 
matter. 

If there are wounds of any kind through which infection takes 
place their edges will become red, swollen, tense, and angry in 
appearance. 



130 ORAL PATHOLOGY AND PRACTICE. 

In addition to these general indications there will be local 
manifestations, which may assist in making a diagnosis. 

If the pus* pocket is superficial there will be "fluctuation," or 
that feeling beneath the finger of softening, yielding, and undula- 
tion that is the sure sign of the presence of a fluid. The abscess will 
begin to "point," — to determine toward a single spot and to show 
an angry, red, or softened elevation above the general surface. 

If the pus is deep-seated and "pointing" is not indicated, or is 
toward some cavity within the body, the superincumbent tissue 
will appear glistening, and will lose its elasticity. If indented with 
the finger it will blanch, and the color will not at once return to it 
upon removal of the pressure, while the indented pit will persist 
for a little time because of the loss of resilience or springiness. 

Treatment. 

Abortive measures should be instituted in the early stages of 
the pericemental inflammation. At this time counter-irritants, hot 
foot-baths, with laxatives and diaphoretic remedies, will be found 
useful. If a dead pulp is present, the pulp chamber should be 
opened under the strictest antiseptic precautions. 

The rubber-dam should be placed upon the tooth, to segre- 
gate it from the septic fluids of the mouth. The drill should be 
carefully sterilized, either by heat or by being allowed to remain a 
little time in some germicidal fluid. Debris should be removed 
from the cavity of decay, if such cavity exists, and it should be 
effectually sterilized with a bichloride or some other energetic 
solution. As soon as the walls of the pulp chamber are punctured, 
the drill should be withdrawn and a sterilizing solution injected or 
carried in upon a pledget of cotton. The opening may now be 
enlarged, and the antiseptic or germicide carried to every possible 
point of the pulp cavity and canal. With a sterilized broach, all 
debris and remains of the decomposed pulp should be removed, and 
the canals made as clear of obstruction as possible. A few fibers 
of cotton dipped in some antiseptic, such as one of the essential 
oils, may be carried as near the apex of the root as possible, and 
sealed up in the cavity. If there is much pain, some anodyne, like 
tincture of opium, may be introduced into the canal on a very few 
fibers of cotton. 

This treatment, both local and general, should be continued 



SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. I3I 

until the inflammation with its soreness and pain shall have passed 
away, when operative measures for the preservation of the tooth 
and its protection from further attacks may be instituted. 

If from any cause the treatment shall prove ineffectual, the 
inflammation gradually becoming worse until the symptoms give 
indication that resolution cannot be expected, that degeneration 
has already commenced and septic infection has taken place, the 
treatment should be promptly changed, and suppuration encouraged. 
The general abortive measures must be abandoned, and the pus 
directed toward the surface. Warm fomentations may be used, a 
cloth wrung out in hot water being applied to the face over the 
seat of trouble, and carefully covered, while the patient is kept 
warm. Indications of "pointing" must be carefully noted, and 
any tendency toward the exterior of the face should be re- 
pressed by painting it over with an iodine solution, the application 
of cold, and other like measures. A poultice consisting of the 
fresh surface of a split fig, or raisin, that has been warmed and 
softened in hot water and sprinkled with capsicum or red pepper, 
should be placed over the alveolar wall opposite the root of the 
tooth, or within the oral cavity where it is desired that the abscess 
shall point, and suppuration invited by that channel. This process 
should be hastened by every available means, that the formation of 
secondary pockets, with osteitis, or inflammation of the bone 
corpuscles, may be avoided. If the indications are that the pus is 
burrowing in the wrong direction, thus threatening a prolongation 
of the condition, with the probable infiltration of the bone by 
septic products, the practitioner should lose no time in reaching the 
disturbed place with an instrument, and thus establishing a sinus 
at the proper point. 

The pus evacuated, the next step should be the disinfection of 
the whole territory. The pulp chamber should be opened and 
cleaned out, and the principal foraminal opening made patulous. 
About the extremity of the point of a suitable metal syringe, a rope 
made of a sufficient quantity of cotton fibers dipped in a chloro- 
percha solution may be wound, the point introduced into the cavity 
of decay, or that artificially made into the pulp chamber, and the 
cotton then closely packed around it. The barrel of the syringe 
filled with tepid water may now be attached and considerable force 
used until the stream entering at the pulp chamber emerges at the 



I32 ORAL PATHOLOGY AND PRACTICE. 

fistulous opening. The barrel of the syringe is now removed and 
filled with a solution of three per cent, pyrozone, or with electro- 
zone, and this is injected as a disinfectant. This is succeeded by 
a solution of bichlorid of mercury or some other effective germi- 
cide, and the cavity may be sealed up for a day or two. 

It may be advisable to wait for a little time after an abscess 
shall have broken or been opened before this cleansing and steriliza- 
tion is attempted, that the pus may be well evacuated and the acute 
symptoms have had time to subside. It is well to establish the 
sinus and wash out the tract primarily, because if a coagulant is 
employed before the pus is removed there may be such a clot 
formed as will effectually stop the channel. 

If at the end of sufficient time the indications warrant the 
belief that sterilization is complete, and that there are no secondary 
pockets of infection, the root may be permanently filled. If, how- 
ever, the septic condition continues in the least degree, or if there 
are signs of osteitis, the cavity should be opened and the sterilizing 
process repeated, or an antiseptic anodyne introduced still further 
to test the case. 

If the fistula is an old one and the abscess not of recent forma- 
tion, and especially if there are no acute symptoms, thus indicating 
a chronic condition, something more active should be introduced 
as an antiseptic. After the cleansing out of the pulp chamber and 
the root canal, the rubber-dam should be applied and a broach 
wound with cotton fibers dipped in a saturated solution of carbolic 
acid introduced, and the caustic antiseptic pumped through the 
tooth and along the sinus until it appears at the fistulous opening, 
where it may readily be detected by its turning the tissues white. 
This cauterizes the whole tract, inducing sloughing to a limited 
extent, and brings on acute symptoms, with effusion of plastic 
lymph, which in the thoroughly sterilized territory may be built 
into tissue by regular progressive metamorphosis. 

A solution of chloride of zinc, five grains to the ounce, may be 
forced through with a syringe in these chronic cases, and this may 
bring about an acute condition and stimulate the indolent functional 
activity. Some operators proceed at once to fill after a single treat- 
ment such as has been indicated, but unless there are special rea- 
sons for haste it is better and safer to' wait until it has been 
thoroughly demonstrated that there are no secondary pockets or 



SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. 1 33 

foci of infection, and until the reparative process and the up- 
building of the waste territory has fairly commenced. This may 
usually be determined by the dryness of the root canal. To test 
this a fine broach should be thrust to the apex of the root, or as 
far as possible, quickly withdrawn and wiped upon a piece of 
rubber-dam. Any moisture will show at once, and will indicate 
that there is still a septic condition. 

There are instances in which it is impossible to force fluids 
through the foraminal opening or openings. This will more fre- 
quently be the case with the molar teeth, in which perhaps the 
infected point will be at the opening of one of the buccal roots, but 
it may occur with even the anterior teeth. Some operators insist 
that they are able to open the apices of such roots with a drill, but 
when it is recollected that seldom or never is the foraminal opening 
in a direct line with the canal, it will be found that none except 
men of the most phenomenal skill will be equal to this task. The 
average operator will hesitate before proceeding to such heroic 
measures. 

If it is impossible to pass a flexible broach through the 
foraminal opening, or to establish communication between the out- 
side and the inside of the apex of the tooth, after the cleansing of 
the canal and the use of the general remedies recommended, the 
antiseptic may be introduced on a few fibers of cotton as near the 
apex as possible, and then sealed up within the tooth. The agent 
used should be one that is of as penetrating a nature as possible, 
and the experiments of Miller show that in this respect none 
possess any special advantage over pure carbolic acid. The pulp 
chamber and canal should be completely flooded with the remedy, 
and it should be changed as often as necessary, sometimes every 
hour, until the pulp canal is thoroughly and completely sterilized. 
Then by slow infiltration and absorption it will be carried beyond 
the apex of the tooth and sterilize the investing tissues. It may be 
necessary to continue such treatment for some time, especially when 
the inflammation is of an indolent, subacute character. But when 
the process is complete the sinus that may have existed will dis- 
appear, and all inflammatory signs will depart. 

Treatment from the outside is the only resource in those in- 
stances in which none of the usual curative measures are effectual. 
Sometimes it is impossible to get through the foraminal opening, 



134 ORAL PATHOLOGY AND PRACTICE. 

or perhaps the dentist has been too precipitate in filling the root 
and tooth with a material that it is difficult to remove. In such 
a case the seat of disturbance must be reached by establishing 
a sinus, or through that already in existence. With a properly 
shaped spring-tempered probe it is usually possible to follow the 
course of a discharging canal to> the apex of the root. A few fibers 
of cotton wet with a solution of carbolic acid should first be intro- 
duced as an obtundent and cauterant, and allowed to remain for a 
short time. The probe is then introduced and the sinus carefully 
explored to its extremity. It will usually be found that the open- 
ing through the external alveolar wall is considerably above the 
fistulous opening, and its course may not be a direct one. But a 
little patience, with the knowledge obtained by some experience, 
will enable one to reach the apex of the root with comparative 
readiness, provided the lesion is not upon the palatal root of a 
superior molar. Having clearly outlined it, the opening may now 
be enlarged with a trephine or drill, if it is necessary, and the 
proper remedies carried to the diseased point. Deposits may be 
removed from the root, or its apical point amputated if necessary. 
All debris having been removed, and the parts carefully sterilized, 
granulation from the bottom will probably close up the opening. 
If it does not, the operator may be assured that there is dead or 
foreign matter in the cavity, or that it has not been effectually 
sterilized. 

In filling a sterilized devitalized root, it is not at all essential 
that the filling material shall be pushed farther than the junction 
of the dentine and cementum, at the point where the division of the 
canal into the foraminal delta begins. The broach will readily 
indicate this point, because it is sensitive beneath it. It is only the 
dentine that is devitalized, the cementum which forms the real 
apex of the root retaining its vitality. The delta or divided canal 
exists within the living cementum, and hence does not need to be 
filled. Dentists sometimes find this point exceedingly sensitive, 
and imagine that the pulp is not yet wholly devitalized. They per- 
haps introduce a second application of arsenical paste, and so do 
considerable injury. They should remember that the cementum at 
the apex is probably in an irritable condition, and needs an anodyne 
rather than another dose of a corrosive poison, the effect of which 
upon the already inflamed living corpuscles may be to induce death 
of the cemental apex and necrosis of the investing tissues. 



DEPOSITS UPON THE TEETH. 1 35 

There are instances in which the inflammation stops short of 
the formation of pus and results in an indurated mass, sometimes 
of considerable size. The plastic exudate has been poured out, and 
has infiltrated the tissues and caused a distinct swelling. But the 
degenerative process has not begun, either because there is no 
septic infection or because sterilization has destroyed the organism. 
The inflammation is of a low, subacute character, and there is no 
pain or violence. The plastic exudate loses its usual consistence, 
either through the extraction of its watery part or because of some 
fibrous organization or other change, and becomes indurated. 
The swelling is perhaps within the bone, and there is a distinct 
protrusion of the external wall. This condition may remain for 
an indefinite time, and it sometimes causes considerable deformity 
of the jaws. 

If this is the result of a pericemental inflammation at the apex 
of a devitalized tooth, resolution or reabsorption may usually be 
brought about by the injection through the tooth of tincture of 
iodine. If the foraminal apex is not open, cotton saturated with 
tincture of iodine may be sealed up in the tooth cavity, and 
changed as necessity requires, until the process is completed. If 
the offending tooth is extracted, there will usually be immediate 
resolution, but this is not always advisable, and the iodine treat- 
ment may be resorted to for the slow relief of the indurated con- 
dition. 



CHAPTER XXIX. 

DEPOSITS UPON THE TEETH. 

Under this head will be considered such superficial precipi- 
tates of inorganic matter as may induce possible pathological 
changes. They must be derived either from external sources or 
from some of the fluids of the mouth or the body. There are 
many forms of oral debris, the sediments of organic matter, 
deposits of food, etc., that will not properly come within this cate- 
gory. The "white deposit," that cheesy deposition that is so often 
found encircling the cervical portion of the tooth and forming a 



136 



ORAL PATHOLOGY AND PRACTICE. 



narrow white line just at the gum margin, belongs to the latter class. 
Jt is composed of the debris of food that is partially fermented, 
micro-organisms, etc., and when it has been allowed to remain 
for any length of time the tissue immediately beneath it will be 
found partially decalcified and softened. But the deposit it- 
self is not of a calcareous nature, and is easily removed by the 
brush. 

The so-called "green stain" of childhood is wholly superficial 
and has no special pathological signification, except so far as it may- 
he a symptom of some unhealthy condition of the fluids of the mouth. 
It is called "green" stain, although it may be dark, or bronze, or 
yellow in color. It has by some been considered a disease-pro- 
ducing kind of fungus, which penetrates the substance of the 
enamel, disintegrating it, and thus injuring the tooth. But if one 

Fig. 39. 




Green Stain on the Approximal Surfaces of Incisors. 
(W. D. Miller.) 



will immerse a tooth discolored by it in a ten per cent, solution of 
lactic acid he will in a few moments see the so-called Nasmyth's 
membrane separate from the tissue, and it will carry with it all the 
deposit, leaving the exterior white and uneroded. Sometimes it is 
found upon the surface of eroded or even decayed enamel, but it 
can be removed in such a manner as clearly to indicate that it was 
deposited subsequent to the erosion or caries. (See Fig. 39.) 

Salivary calculus is a deposit from the saliva. If one will 
through a tube breathe into a glass of lime-water, he will soon 
observe that the fluid becomes milky in appearance. If he will 
continue the process for a while, and then set the glass where it 
will be entirely undisturbed, he will after a time find deposited 
upon the bottom more or less of a fine amorphous powder. This 



DEPOSITS UPON THE TEETH. 1 37 

is the calcium that was held in solution in the water, and which 
was thrown down as carbonate of lime. A few drops of hydro- 
chloric acid will clear up the fluid by again dissolving the pre- 
cipitate. 

It is not asserted that this is the method in which salivary 
calculi are formed, but it illustrates the precipitation of calcific 
matter. The calcium salts are really held in solution in the saliva 
by means of the carbon dioxide which it contains. When the fluid 
enters the oral cavity it at once encounters acids which may be 
present, and is subjected to fermentative and other active and 
chemical influences, which result in the precipitation of the calcium 
salts, and these, with some extraneous matter, form the calculi. 
Naturally, this deposition will be greatest near the mouths of the 
salivary ducts, and so> the principal calculi are upon the inferior 

Fig. 40. 

B 





a 

a. Salivary Calculus Causing Recession of Gum and Absorption of Alveolus. 

b. Molar with Deposits of Sanguinary Calculus at b. At a Necrotic Perice- 
mentum and Broken Down Exudate. 

incisors, opposite the mouths of Wharton's duct, and upon the 
superior molars in the neighborhood of the discharging mouth of 
the duct of Steno. (See Fig. 40, a.) 

Sometimes this material is precipitated in great quantities, 
binding several teeth together in one mass. In some instances the 
utmost care of the patient will not enable him to keep the teeth 
entirely free from it. When this is the case it is usually soft, of a 
creamy yellow color, and is easily removed. When it is deposited 
more slowly it has time for consolidation and becomes hard, and is 
usually stained a dark color by pigmentary matter from the oral 
cavitv. 



I38 ORAL PATHOLOGY AND PRACTICE. 

It has no special pathological signification aside from the fact 
that it is a mechanical irritant, and keeps the teeth and mouth in 
a filthy condition by constantly acting as an absorbent, and as an 
obstruction against or under which food debris lodges. It should 
be carefully removed with instruments, the teeth polished, and, if 
necessary, the irritated gums touched with a stimulating astrin- 
gent. 

The so-called sanguinary or serumal calculus is distinguished by 
separate characteristics, and is due to other or modified conditions. 
It is not found external to the margins of the gums, nor does it 
always appear to be a precipitate from the oral fluids, — for no refer- 
ence is here intended to the hard, black, smooth, supragingival, slow 
deposit which is but a modification of the usual form of calculus and 
is undoubtedly of salivary origin. The so-called serumal deposits 
are upon the periphery of a root that is not denuded when they are 
formed. They may be found when there is absolutely no break at 
the gingival border, and when consequently their precipitation from 
the oral fluids would seem to be an utter impossibility. Instances 
of this are cited in the chapter on Pyorrhea. (See Fig. 40, b.) 

It is not deposited in a smooth, continuous, amorphous mass, as 
in the case of salivary calculus. It is found in dense, hard, closely 
attached, separate nodules, which may by further deposition become 
confluent. 

It cannot be scaled off cleanly and readily, as can the oral 
variety. It clings so closely as to make it necessary to chisel it 
away, in which process, unless great care is used, a scale of the 
tooth may be taken or a thin layer of the deposit left. It has riot 
the same color as the salivary concretion, the latter, except when it 
has been discolored by subsequent pigmentary deposits or infiltrates, 
being of a dark yellow or yellowish white color. The so-called 
serumal or sanguinary deposit is of an olive-black tint, with some- 
times an olive-green tinge. It is not identical, either in color or 
in manner of deposition, with salivary concretions. 

It is more distinctly irritating to the tissue than is the salivary 
deposit. Perhaps the location of it within the tooth socket may 
serve to account for the difference, but aside from that there appears 
to be a rather distinctive irritation in its presence, not known in 
connection with the salivary deposit. 

Chemical analysis shows that there is a synthetic difference 



DEPOSITS UPON THE TEETH. 1 39 

between the two, for, while calcium forms the base of both, the 
serumal contains certain elements not found in the other. The 
analyses of it have not been sufficient in number or so exhaustive 
in character as to reveal all that may probably be learned from 
them. 

Perhaps the most reasonable and consistent theory of the 
formation of this calculus is that of Professor E. C. Kirk, and it 
may be thus summarized: The capacity of the blood stream for 
holding in solution the waste products of nitrogenous metabolism, 
the results of functional activity in the body, is determined by the 
alkalinity of the blood plasma. Any decrease in this diminishes 
its solvent power for these, and causes their precipitation in the 
tissues nourished by the blood stream. This lessened alkalinity 
may be general, affecting the whole sanguinary current, or it may 
be localized in certain tissues ; in the latter case there will be a 
localized precipitation of the products of which uric acid is a type. 
Excessive work causes an increased blood supply to a part, and 
excessive oxidation and tissue waste, which in turn produce les- 
sened alkalinity, or a tendency toward acidity. The ligamentous 
tissues are especially liable to conditions of this nature, and- the 
peridental membrane, belonging to this category, is especially sub- 
ject to affections of the character noted. Excessive work being 
put upon the investing membrane of any tooth, through mal- 
occlusion or by bad habits in mastication, by injuries from wedging, 
the application of ligatures, or other causes, the resulting hyperemia 
brings in its train overnutrition, localized diminished alkalinity, 
with the consequent deposition of urates. 

Professor Kirk believes that changes identical with or 
analogous to those cited above are responsible for other local necro- 
biotic degenerations. They may be the exciting cause of alveolar 
abscess, through a diminishing of local physiological activity and 
lessening of the resistant power of the tissue, which, being in- 
fected, leads to suppuration of the pericementum, that has been 
variously denominated pyorrhea alveolaris, phagedenic perice- 
mentitis, or suppurative alveolitis. Under certain other definite 
conditions the pathological changes may result in a hyperplasia 
of the tissues, and hypercementosis and hypertrophies of the peri- 
cemental membrane may be the result. 

It is, then, accepted that this calculus is and must be derived 



440 ORAL PATHOLOGY AND PRACTICE. 

from the blood, through the pericementum. Certain it would seem 
to be that the trouble is not in the tooth itself, for the cementum 
does not appear to be affected in any way, further than secondarily 
through the mere mechanical separation from it of the perice- 
mentum. One reason for supposing that it is not due to a con- 
stitutional dyscrasia, that it is not a manifestation of a general 
disorder, but rather a symptom of a local degeneration or disturb- 
ance, is found in the fact that it is usually confined to one or two 
teeth. 

The early presence of sanguinary calculus is not easily deter- 
mined. Salivary calculus exhibits itself unmistakably to the eye, 
and so there can be no error in its diagnosis; but such is not the 
case with the sanguinary concretion. It is hidden within the tooth 
socket at a point where examination is impossible. No special 
prophylactic measures can therefore be employed. There may be a 
localized inflammation, with pustular swelling, but this comes too 
late for preventive measures. When a pocket reaching down to 
the deposit has been formed from the gingival margin, there is 
nothing left but its instrumental removal. 

There are instances in which pericemental irritation and sore- 
ness may, to the expert, give some warning of nodular formations. 
But these are too easily confounded with those which may be 
caused by hypercementosis, or by the presence of any other 
foreign substance, to afford a positive pathognomonic sign. 
When we comprehend the morbid changes of the disease better 
perhaps we will recognize premonitory indications, but, as it is, we 
must wait for its development. The usual revelation will come 
through the formation of the characteristic pockets beside the 
affected tooth, and the point of irritation, when near the apex of 
the root, may in some instances be detected by the localized 
inflammation and swelling. The local treatment for the condition 
is laid down in the chapter on Pyorrhea Alveolaris. 



PYORRHEA ALVEOLARIS. I4B 

CHAPTER XXX. 
PYORRHEA ALVEOLARIS. 

Pyorrhea Alveolaris has been denned by Kirk as a necrotic, 
suppurative, inflammatory process which destroys the pericemen- 
tum, and by setting up an osteomyelitis in the alveolar margins sub- 
sequently destroys them also. He believes it to be caused by the 
invasion of certain pathogenic organisms which are the exciters 
of the inflammatory process. The depth of the bacterial invasion 
determines the seat or location of the inflammation, and is condi- 
tioned upon the degree of vital resistance of the tissues invaded. 
Given low vitality in the pericemental membrane, the invasion is 
deeper, and the pyorrhea is established by the breaking down of 
tissue and the establishment of a pocket through the working out 
of the products of the inflammatory action at the gum margin. 
Given high vital resistance in the pericemental membrane, the dis- 
order produced by these inciters of inflammation becomes superfi- 
cial ; that is, ulcerative in type. 

The depression of vital resistance may be either constitutional 
or local. If the former, it is brought about by a chronic toxemia, 
the result of auto-intoxication caused by malnutrition and the im- 
perfect elimination of the waste products of tissue consumption and 
repair. These toxic substances in the blood stream are irritant in 
character, and manifest their action in the pericemental membrane 
by the production of hypercementosis and by other changes. When 
the predisposing factor is purely local, as in the case of salivary 
calculus impinging on the gingival margin, the depression of 
vitality is entirely superficial, affecting only the layer of cells in 
contact with the calculary deposit. The invasion of pathogenic 
germs is also superficial, the high vitality of the healthy tissue 
beneath preventing deep invasion, and the type of the necrotic and 
inflammatory process is ulcerative. 

It is not a matter for boastfulness that for so long a time so 
little should have been positively known concerning a disease that, 
after caries, is responsible for the loss of more teeth than any other. 
It is but recently that any attention whatever has been paid to it. 
For many centuries it has been doing its destructive work without 



I42 ORAL PATHOLOGY AND PRACTICE. 

remark and without any attempt to determine its pathology. Not 
alone in man is it prevalent, but many animals suffer from its 
ravages. Domestic cats are especially liable to its attacks, while 
dogs are far from exempt. Horses sometimes suffer extremely 
from pyorrheal affections, but their teeth are not as often extruded 
and lost, because of the length and shape of the roots, which do 
not end in a closed foraminal opening. None of the teeth of per- 
sistent growth in the various orders of animals are materially 
affected by these discrders, so far as the author is aware. But he 
has in his possession the skull of an African gorilla, an animal that 
it has been found almost impossible to keep in captivity, in which 
the characteristic appearance of this disease exists unmistakably. 

The condition has been known by various names. The late 
Dr. J. M. Riggs, of Hartford, Conn., was probably the first to call 
public attention to it, about the year 1850. For some time it was 
called from him "Riggs's Disease," but the impropriety of this 
being manifest, the term Pyorrhea Alveolaris was proposed, and 
has been generally accepted. Prof. G. V. Black has denominated 
it "Phagedenic Pericementitis." Dr. J. N. Farrar has proposed the 
name "Loculosis Alveolaris," from the fact that, very often at 
least, it has its origin in a kind of pocket beside the alveolus. 
Others, recognizing a communicable nature, have denominated it 
"Infectious Alveolitis." When its true nature and exact pathology 
are more fully ascertained, a term that is descriptive of it will un- 
doubtedly be universally accepted. In the meantime Pyorrhea 
Alveolaris, which signifies a discharge of pus from the alveoli, 
although somewhat indefinite, is as applicable as any. 

It has been intimated that the exact nature of the disorder 
has not yet been decisively determined. At least no exposition of 
it has been commonly accepted. Many theories have been offered, 
and some of exceeding plausibility are now before the dental pro- 
fession ; but, so far, none has received that general acceptance which 
excludes all other hypotheses. That its seat is within the alveolar 
socket is easily demonstrated, and that either the tooth root or its 
investing membrane is an essential factor in its existence is quite 
plain, for extraction always affords a radical cure. Beyond this 
there is no admitted certainty concerning its' etiology. Professor 
Black believes the initial point to be in the pericementum. Others 
have held that it commences with a degenerative condition of the 



PYORRHEA ALVEOLARIS. I43 

investing margin of the alveolar process. Prof. W. D. Miller says 
that there are three active factors in its production: constitu- 
tional diathesis, local causes, and micro-organisms. 

Perhaps the hypothesis that has attracted the most attention 
tip to this point is that which has been so strenuously urged by 
Prof. C. N. Peirce and others, that it is but an expression of the 
uric acid diathesis, and is closely allied to gout, rheumatism, and 
allied disorders. It has been asserted, indeed, that it is always con- 
nected with them, either as a forerunner, a successor, or a substi- 
tute. It has been argued that as urea is the effete product of the 
using up of tissue in functional activity, which the excretory organs 
should eliminate, its presence in the body is an indication of 
inactivity on their part. It is undoubtedly true that such effete 
matter must, from its very nature, by its continued presence excite 
a more profound influence than would any innoxious foreign sub- 
stance. We all know the extreme violence and general character 
of the protests of all the tissues of the body against its presence 
when manifested in uremic poisoning. 

The dense, hard, dark-colored nodules sometimes found upon 
the roots of teeth, and which are considered in Chapter XXIX., 
dealing with salivary and sanguinary calculi, it has been claimed 
are induced by and contain the urates of the blood, and are prime 
factors in inducing the pyorrheal condition. Could these asser- 
tions be substantiated as indisputable facts in all cases, they would 
be conclusive. But it is urged in answer that it is not positively 
demonstrated that the concretions referred to have their origin in 
the blood, that they are necessarily an expression of the uric acid 
diathesis, that they invariably contain any uremic salts, are at all 
essential to the pyorrheal condition, or are in any considerable 
proportion of instances the cause of it. They point to the fact that 
while they may be frequent or even usual concomitants, pyorrhea 
exists in its worst form without the presence of any such deposits, 
and quite unconnected with either gout or rheumatism. In the 
midst of this conflicting mass of evidence the only sure conclusion 
at which it is possible to arrive is that the subject has not yet been 
sufficiently considered, and that we have not verified ultimate 
facts. There is abundant cause for investigation and observation, 
and every real student should strive to add something to the knowl- 
edge of the subject, until enough has been learned to form a basis 



144 ORAL PATHOLOGY AND PRACTICE. 

on which to build an hypothesis that shall be unassailable. Some 
patient investigator will yet solve the problem, as Miller gave us 
the solution of that of dental caries, which was for so long a time in 
the same unsatisfactory, unsettled, disputed condition. In the 
meantime it only remains practicable to present as clear an expo- 
sition as the present state of knowledge will permit. 



CHAPTER XXXI. 

PYORRHEA ALVEOLARIS (Continued). 

True Pyorrhea Alveolaris should be a manifestation of some 
distinct, perhaps specific, pathological condition. The term itself, 
while expressive of our present knowledge, is too broad, covering 
altogether too much, for there are many exudations of pus from 
the alveolar walls that are easily explainable, and of very simple 
origin. But until its exact nature is distinctly marked out, and all 
its phenomena comprehended, we must recognize at least three 
separate pathological degenerations that are covered by the term, 
and which without doubt are often confounded with each other. 

The first of these will be entirely local in its character. It 
will have its origin in an easily comprehensible cause — local irrita- 
tion. 

The second will have its etiology in deposits of a hard, nodular 
character upon the roots of the teeth. It will be distinguished by 
the formation of distinct pockets within the alveolus. 

The third will give evidence of some distinct cachectic condi- 
tion or dyscrasia. It will present phenomena that are peculiar 
to itself, and will be without either of the two previously named 
factors. 

The first condition is a localized gingivitis, with possible alveo- 
lar caries, or a slow solution of the alveolar edges. It is charac- 
terized by inflamed, turgid gums, which are everted at the cervix. 
There will probably be a degenerate mucous secretion of a viscid 
character and acid in reaction. The gum is not adherent to the 
teeth, and the point of an instrument can be passed between them. 
Instead of the hard, dense appearance that the gingivae usually pre- 
sent, they bleed at the slightest touch. A little pus can be forced out 



PYORRHEA ALVEOLARIS. 145 

from between the gum and tooth, but it is small in quantity and 
thick in consistence. The patient gives the teeth but little care, 
and they usually present anything but a healthy appearance. The 
redness is principally confined to the gum margin, and there are 
few or none of the peculiar red blotches higher up that are indica- 
tive of pericemental inflammation. An explorer cannot be passed 
up far beneath the gum, and, with the exception of roughened 
edges, the alveolar process is perfect. 

The prognosis of this condition is always good. The first care 
should be thoroughly to clean the teeth, and to remove from about 
their necks, especially from beneath the gums, any foreign sub- 
stances that may have accumulated. Not infrequently delicate 

Fig. 41. 




Gingival Destruction of the Pericementum with Resorption of the Alveolar 
Borders, due to Pyorrhea of the Third Variety. 
There are no deposits and little if any suppuration. The destructive process has entirely- 
denuded one root, and the alveolar walls inclosing the others are very thin. (Burchard.) 

rings of salivary calculus will encircle them close up to the alveolar 
border. All traces of this must be removed, and the necks of the 
teeth be carefully polished. Sometimes foreign substances, like 
slivers from wooden toothpicks, or spiculae of bone from the food, 
will be found driven beneath the gums, and these will be the 
source of irritation. After careful cleaning the gums should be 
well rubbed, and a soft tooth-brush, with some antiseptic wash, 
should be prescribed. Listerine is good for this purpose, or any of 
the pleasant essential oils, largely diluted. Care and cleanliness, 
with the removal of every foreign substance, will be sufficient to 
produce a cure, for the condition was only the result of a lack of 
attention, and the irritating presence of foreign substances. 

The second condition is one of greater moment. It is charac- 



I46 ORAL PATHOLOGY AND PRACTICE. 

terized by the presence of deep pockets in the alveolus, at one side 
of the anterior teeth, or perhaps between the roots of the premolars 
or molars. There may be. little of the turgidity or tumefaction 
described in the previous paragraph, but an exploration with an 
instrument will detect a resorption of the alveolar walls of the tooth 
socket, and pus may be forced out. Often the tooth, especially if 
it is one of the six anterior ones, will commence an inclination 
away from its neighbor. It loses its upright position, perhaps falls 
out of the line of the arch, and the previous regularity of a well- 
ordered dentition becomes sadly broken. The affected tooth is 
always deflected from the side on which is the pocket, and not 
toward it. A more careful exploration of this pocket will usually 
detect, well up toward the apex, or along the body of the root, 
dense, hard, gritty nodules, that are closely attached to the side of 
the root, enveloping more or less of the surface that has been 
denuded of its pericemental membrane, but which is yet covered by 
the gum. These are the sanguinary deposits described in a previ- 
ous chapter. 

Whether these are the cause or the result of the diseased con- 
dition has formed a fruitful subject of discussion among etiologists. 
Those who believe them to be deposits from the fluids of the mouth 
insist that there must be some connecting opening between^them 
and the oral cavity, along the side of the tooth. But competent 
observers have described instances in which there absolutely was 
none. One such case fell within the observation of the author. 
His associate in practice found opposite the lower third of the root 
of a lower central incisor, in the mouth of a woman who took excel- 
lent care of her teeth, a peculiar swelling that had somewhat the 
appearance of incipient alveolar abscess, but which had none of the 
other symptoms that attend that disorder. The author counseled 
pursuance of the expectant plan, and waiting for developments. 
In a very few days pus gathered in a comparatively small amount, 
and was discharged. The opening was enlarged, and opposite it 
were the characteristic nodules of the so-called sanguinary or 
serumal calculus. Yet the gingivae were absolutely unbroken, 
and there was not the slightest indication of irritation about the 
neck of the tooth. The nodules were carefully removed, the open- 
ing antiseptically dressed, when it healed, leaving no sign whatever 
of the lesion, nor has any since appeared. If the hypothesis pre- 



PYORRHEA ALVEOLARIS. I47 

sented on a previous page is accepted, the presence of these nodules 
is accounted for. But there were in this patient no indications of 
either local or general anemia or lack of tone, while the tooth was 
one of a nearly perfect set, a lower incisor, not subjected to unusual 
strain or labor. Upon removal of the calculus it returned to a 
normal condition, and has so remained for some years. 

It must be accepted that, in some instances at least, the serumal 
nodules are the first indications of the disturbance. Whether 
these are the result of any special diathesis we need not now further 
inquire. We know that they are specially irritative in their nature. 
If they form the initial point of the disorder, the subsequent patho- 
logical changes may be easily comprehended. They lift the peri- 
cementum from the tooth, and by their presence originate the 
breaking down of tissue. Infection follows, and the pus forces its 
way to the gingival margin, thus making an opening into the 
pocket already formed. Or perhaps the pocket is completed by the 
continuation of the deposits to the gum margin, the infection being 
subsequent to this. Perhaps, in a proportion of the cases, the 
deposition of the calculus commences at the neck of the tooth and 
proceeds toward the apex, forming the pocket from the margin 
instead of from the interior of the alveolar socket. In any case, 
there must be organic or functional degeneration of the perice- 
mental membrane as the immediate or proximate cause of the dis- 
turbance, and the attention of the practitioner should be directed 
toward such local or constitutional remedies as will prove effectual. 

The prognosis of this condition depends upon the ability com- 
pletely to remove the deposits, and upon the general tone of the 
system, or its ability to bring about a restoration of the lost tissue, 
and a healthy tone in that which remains. The first remedial meas- 
ure is thoroughly to cleanse the teeth and pockets. This must be 
the work of time and patience. If the disease has extended so far 
as to induce much soreness and looseness of the tooth, it cannot be 
accomplished without considerable pain. So dense and closely 
attached 'is the deposit in many cases that a sharp, stiff chisel, with 
considerable force, is demanded. The drawing motion of a scraper 
is insufficient. Only the thin edge of a chisel will reach the last 
particle, which may lie just at the point of separation uf the perice- 
mentum from the tooth. 

There is no chemical agent that can be depended upon to dis- 



I48 ORAL PATHOLOGY AND PRACTICE. 

solve the deposits away without injury to the surrounding bone and 
tooth. The usual mineral acids attack the latter quite as readily as 
the concretion. Trichloracetic acid has been found of benefit in 
softening it, so that it may more readily be removed with instru- 
ments. This may be used in from twenty to fifty per cent, aqueous 
solution, the exact strength to be determined by trial. It should 
be carried to the extremities of the pocket on a narrow, wedge- 
shaped piece of orange wood that has been dipped in the solution, 
and by a pumping motion continued for a sufficient length of time 
every nodule may be saturated with it. Or it may be carried upon 
a rope consisting of a few fibers of cotton wet with the acid. Dr. 
W. J. Younger, who has made a specialty of the treatment of 
pyorrhea, uses and recommends lactic acid for the same purpose, 
and claims that it has special therapeutic value in this disease. 

It may be necessary to repeat the operation more than once, 
carefully chiseling or scraping off all that is practicable each 
time, until the root is clean and polished. The pockets should be 
washed out and treated antiseptically. Finally, when all the deposits 
are removed, a weak solution of chloride of zinc may be injected as 
a stimulating astringent. It may be necessary to freshen the 
alveolar edges with a hoe excavator, or a safe bur, to induce new 
granulations. When there has been an effusion of coagulable 
lymph it should be protected, and not carelessly wiped or washed 
away. To this end it is necessary to know when to stop active 
surgical or operative measures, and to leave the rest to the vis 
medicatrix nature?. Pursuing this course, the author has had the 
great satisfaction of seeing pockets that reached almost or quite 
to the apex of the root, and into which a considerable quantity of 
cotton could be packed, completely healed and filled with a new 
growth of bone through the action of a newly-formed perice- 
mentum. 

The prognosis of the third condition is almost invariably bad. 
It seems to be connected with some vicious constitutional condi- 
tion that prevents eradication of the disease. There is frequently 
very little if any gingival inflammation. There is no- thickening 
or tumefaction, and but little redness of the gums. Perhaps they 
may even be abnormally pale and bloodless. There are none of 
the pockets of the preceding conditions, but there is a steady 
wasting of the alveolus, a continual recession of the gums, with 



PYORRHEA ALVEOLARIS. I49 

a constant and sometimes profuse discharge of pus from the 
sockets of the teeth. In the pocket form a single tooth may be 
affected, but in this state it usually spreads from tooth to tooth, 
until all or nearly all of either or both jaws become affected. There 
is no special pain, or any great degree of soreness until the later 
stages are reached, when the loss of the teeth seems imminent, and 
when the destruction of tissue goes on with such rapidity that it 
almost assumes the acuteness of alveolar abscess. 

There may be no deposits of any kind. The condition may 
occur in the mouths of those who are fastidious in the care of their 
teeth, and who regard its insidious but sure advances with horror. 
They fight it with every weapon at command. They may retard it 
for years, but it is seldom that it is entirely eradicated. The author 
has under his care cases in which it manifested itself twenty- 
five years ago, and though it has been kept in check, sometimes 
by the most radical measures, it still crops out occasionally, and 
he and his patient have never been long entirely separated. 

When a radical cure of this form of the disease has been 
effected, it has usually been because of some constitutional change 
in the general tone of the sufferer. It has ever been prone to attack 
anemic and atonic persons, though it is not confined to them, and 
when it has been eradicated it has been accompanied by a com- 
plete change in the bodily health of the patient, and a return to a 
tonic state. 

The treatment of this special condition must, to a considerable 
degree, be general in its nature. If it is due to a want of eliminative 
power in the body, it may be that a prolonged course of alterative 
and tonic treatment will be necessary to enable the system to recover 
and maintain its normal tone. If there is any distinct diathesis 
with which it may be connected, that should be attended to. 
Antiseptics must be constantly used, and the mouth kept as free 
from putrefaction as possible. Stimulating, astringent mouth- 
washes should be frequently employed, and every hygienic pre- 
caution exhausted. The space between the gum and the tooth 
should be kept clean, and whenever necessary it should be wiped 
out with some mild cauterant, like lactic or trichloracetic acid. 
Massage should frequently be employed by rubbing the gum with 
the ball of the finger, using considerable force. The tooth-brush 
should not be too harsh, and washes rather than powders should be 
employed with it. 



I5.0 ORAL PATHOLOGY AND PRACTICE. 

In some instances the author has seen what he thought to be 
good results following the use of anti-gout and rheumatic remedies. 
The employment of lithia in some form, or of salicylic acid, has 
been especially recommended. Dr. E. C. Kirk has reported excel- 
lent results from a persistent use of lithium bitartrate, in the form 
of tablets. 

If a tooth becomes very loose through destruction of the 
alveolar socket it is usually best to remove it, but when it is the 
result of an acute inflammatory stage, it may be held firmly for a 
time by weaving a ligature about it and the adjoining teeth. 
Sometimes there may be a decided amelioration following the 
burring away of the diseased edges of the alveolar process, with the 
use of antiseptics and stimulating astringents, but too often this is 
not permanent. Very little dependence can be placed upon the 
many specific methods and remedies offered by those who claim to 
cure the incurable. The best results will be attained by the practi- 
tioner who, to general medical intelligence, adds the most faithful, 
diligent, painstaking care in the line of treatment adopted. Of 
course, when the whole or nearly the whole alveolar socket of a 
tooth has been lost, further temporizing methods are useless. 



CHAPTER XXXII. 
FACIAL NEURALGIAS. 



Neuralgias are affections of a nerve trunk or filament, and may 
be either organic, constitutional, functional or local in their origin. 
The first of these occur through some organic change in the tissues 
which (renders them incapable of healthy action. The second arise 
from and are associated with a constitutional diathesis. The third 
are due to disturbed nutrition and the consequent lack of tone, 
while the fourth originate in a direct lesion, or in some local irrita- 
tion. An instance of the first is the pain due to cicatrization of a 
wound ; of the second the general neuralgia of gout or syphilis ; of 
the third that of miasmatic affections, while the fourth may be 
found in prolonged dental disturbances. Strictly speaking, any 
pain is a neuralgia, but the usual signification is confined to an 
affection in a nerve trunk as distinguished from that caused by 
irritation of a terminal filament. The continued pain arising from 



FACIAL NEURALGIAS. 151 

a neuromatous tumor is an instance of neuralgia from a true lesion 
of a nerve trunk. 

True neuralgias are principally confined to the afferent nerves, 
but they may be reflex and hence have their origin in the efferent 
or motor nerves. The facial neuralgias that form the majority of 
the affections presented to the notice of the dentist are manifested 
in the trigeminus, and their most frequent cause is diseased teeth. 
The irritation from caries may be so severe, or so long continued,, 
that the trunk of the nerve is affected and its function so modified 
that it remains in a permanently irritable condition. 

The diagnosis of this disorder is not always easy. That is, it is 
sometimes difficult to determine whether the pain arises from a 
mere local irritant, like the inflamed pulp of a tooth, or if it is a true 
degeneration or functional disturbance of the nerve tissue. In 
facial neuralgia the first thing to do is to look for the cause, and to 
determine whether it may not be mere odontalgia, or toothache. 
To this end the most minute examination of the teeth upon the 
affected side should be made. Cavities may exist beneath the gums 
which only the most careful search will reveal. Every test for in- 
flamed and irritated pulps should be tried, and in the great majority 
of instances the suspected neuralgia will be found to be mere tooth- 
ache. 

Every local cause having been excluded, the general bodily 
condition should be noted. If any distinct diathesis exists, like 
that of gout, rheumatism, syphilis, malaria, or catarrh, its possible 
connection with the disturbed neural currents should be looked for. 
If there is a state of anemia, or lack of nutrition, here may be its 
origin. The starved nerves are loudly crying for the sustenance 
they lack. 

All these sources excluded, a neuroma, or some other disor- 
ganization of the nerve tissue itself may be suspected. When 
this is the case and a true neuralgia is indicated, more minute in- 
quiries should be made as to the character of the subjective symp- 
toms. 

If neuralgic, the pain will be unilateral. Though not local, it 
will affect but one side, for bilateral disorders of this kind are 
something more than rare. 

The pain will usually follow the course of the trunk of the dis- 
turbed nerve. That is, it may be recognized at different points in 
the route. 



152 ORAL PATHOLOGY AND PRACTICE. 

It will be sudden in its attack. Its onset will not be a gradual 
approach, increasing in intensity until the climax is reached and 
then subsiding by degrees, but, from entire ease, instantly the 
victim is in the throes of the most agonizing torture. 

It will be of a darting 1 , stabbing, boring character. It is not 
the steady, dull, throbbing, continuous pressure of a pus gather- 
ing. 

It will be markedly intermittent. There will be intervals of 
complete immunity of greater or less length succeeded by 
paroxysms that will end as suddenly as they begin. There may 
or may not be regularity in these attacks. 

In the earlier stages there is usually an increase in severity 
with each paroxysm, to be succeeded by decreasing violence. 
While the invasions are sudden in their attack and subsidence, 
there is a true paroxysmal character to their recurrence, each one 
becoming more severe until the climax is reached, when the abate- 
ment will be as gradual. 

There is no functional disturbance connected with the attacks. 
The pulse will not be accelerated, nor will the temperature rise. 
There is no fever or other general disturbance. This is an im- 
portant pathognomonic symptom. 

In some instances, especially in cases of long standing, there 
will be soreness along the track of the affected nerve. This may be 
especially marked at the foramen of exit. Anesthetic spots in the 
tissues supplied by the disordered nerve may assist in the diagnosis. 

Reflex symptoms in communicating nerves may be exhibited. 
There may be spasms and muscular twitchings. Tears may flow, 
the effect of reflex irritation, or salivary secretions may be markedly 
increased. 

Fatigue and depressing influences bring on invasions, or 
exacerbate them. The receipt of distressing news will possibly 
provoke an attack. Sleeplessness or any unusually prolonged 
exertion will be likely to be followed by paroxysms. 

The clinical history is usually quite distinct and marked. 
Neurotic persons, and those with an unbalanced nervous organiza- 
tion, are especially liable to attacks. Hence the neuralgias are 
frequently closely related to hysteria, migraine or sick-headache, 
hypochondria, paralysis, catalepsy, epilepsy, and other nervous and 
convulsive disorders. Clavus hystericus is but another special form 
of it. 



FACIAL NEURALGIAS. 153 

It usually accompanies or indicates an atonic, debilitated condi- 
tion. It is sometimes among the sequelae of a long-continued fever 
or other exhausting disease. 

It is especially liable to attack those who are suffering from 
malaria or miasmatic fevers. In such instances it sometimes as- 
sumes the form of "brow ague." 

The gouty and rheumatic diathesis seems especially provoca- 
tive of different forms of neuralgia. Among these, sympathetic 
affections of the trigeminus, or fifth cranial pair, are not un- 
common. Indeed, sympathetic pains along the course of com- 
municating branches or nerves, or through those but secondarily 
connected by different ganglia, would naturally be anticipated from 
the very nature of the disorder. It could not well be otherwise 
than that reflected pain would be felt in perhaps distant tissues 
or organs. These may not be of a severe character, and they will 
probably be felt at the outset, or more likely still at the close, of a 
paroxysm. Yet their existence may be an important part of the 
clinical history, and should be carefully sought out. 

Treatment. 

A real neuralgia having been clearly diagnosed, the first thing 
will be. to determine its cause and to remove it. If there is any 
local source of irritation it must be remedied. 

The hygiene of neuralgic patients should be carefully looked to. 

They must be guarded from sudden changes of temperature, 
draughts of cold air, etc. All sanitary precautions must be 
adopted, and if the patient suffers from malaria removal from the 
miasmatic influence is the first consideration. 

Plenty of out-door exercise must be urged, with a liberal, rather 
stimulating diet. Extreme fatigue should be guarded against, and 
bodily and mental rest is important. 

If there is a constitutional or general functional dyscrasia, it 
must be relieved. Nervous sedatives may be prescribed, and gen- 
eral quiet insisted upon. 

Potassium bromide, ten grains in water, from two to ten times 
per day, will be found useful, or tincture of valerian and gentian, 
equal parts in teaspoonful doses. During the paroxysm, digitalis, 
or veratrum viride in five-drop doses may be given, and aromatic 
spirits of ammonia in fifty-drop doses will be found useful. 



154 ORAL PATHOLOGY AND PRACTICE. 

If there is a gouty diathesis, wine of colchicum in small doses, 
frequently repeated if necessary, should be prescribed. 

Muriate of ammonia fumes, arising from the burning of the 
salt upon a hot iron in the room, sometimes give gradual relief. 

If the neuralgia is of miasmatic origin, from three to ten grains 
of quinine should be administered, or Fowler's solution of arsenic 
and potash in ten-drop doses, two or three times per day. 

Hot moist applications to the affected parts are very useful r 
and massage sometimes gives very ready relief, although there are 
instances in which it will be found exacerbating. It must be 
gentle, and not too long continued at first. 

If the paroxysms are very violent, it may be necessary to allow 
the patient to inhale the vapor of ether or chloroform for a short 
time ; of course, not to the point of entire narcosis. 

If none of the usual remedies are effective, and if the 
paroxysms are violent, resection of the affected nerve may be 
necessary. This will, with comparative frequency, be called for in 
neuralgia, especially in that of the inferior dental nerve. Pro- 
fessor Brophy, of Chicago, has greatly simplified this operation, 
and by his method it no longer presents any formidable difficulties. 
His resections of the infra-orbital from the oral cavity also relieves 
that operation from many complications. 



CHAPTER XXXIII. 
FACIAL PARALYSIS. 



In its etiology this affection is closely connected with facial 
neuralgia, but it differs from it in being the effect of lack of nerve 
nutrition, while the neuralgias are more frequently the result of 
overstimulation. It is also more frequently due to organic lesions 
or cachectic conditions. It may arise from syphilis, tubercle in 
the cerebral centers or cord, or a blood clot in the brain. In any 
case, it implies disordered nerve function, and its treatment may 
often properly fall within the province of the oral physician, inas- 
much as facial paralysis is not infrequently due to some oral lesion. 

Facial paralysis is the complete inhibition of efferent neural 
currents in the tissues affected, with usually a local anesthesia, or 
suspension of afferent nerve currents, more or less complete. It may 



FACIAL PARALYSIS. 1 55 

be traumatic or idiopathic in its origin. If the former, there will 
be no difficulty in determining the fact, while in the latter case its 
source will be more obscure. It may be complete or incomplete. 
It is complete when there is a total loss, and incomplete when there 
is only more or less of diminution of function in the nerves. It is 
general when there is loss of power in both the upper and lower 
extremities, and local when it is limited in the number of muscles 
affected. Facial paralysis is local in its character, and as seen in 
oral practice it is usually but partial. 

Paralysis of sensation may be either loss of tactile sense — in- 
ability to receive impressions from external contact — or immunity 
to painful sensations. Thus the skin and the mucous membrane 
of the mouth are endowed with both kinds of sensibility. The 
capacity of these tissues to receive painful impressions may be 
quite impaired, or even lost, while the tactile or feeling response 
to external agents remains. But in these instances the impression 
made by ice, or a hot iron, will not materially differ from that 
derived from a piece of wood. 

Paralysis of the tactile sense is commonly called anesthesia, 
while that of the sense of pain is denominated analgesia. Reflex 
paralysis is a term that has been applied to cases in which a 
paralyzed condition of certain parts is attributed either to a wound 
or shock received from other and more or less remote parts, or to 
a local disease situated elsewhere than in the paralyzed region. Dr. 
Brown-Sequard supposed this to be induced through shock to the 
vaso-motor nerves, thus interfering with the nutrition of the nerve 
centers. 

The instances of paralysis that are of the greatest interest to 
the dentist are those of the fifth and the seventh pair of cranial 
nerves. The fifth, or trifacial, is the great sensory nerve of the 
head and face and the motor nerve of the muscles of mastication, 
while the seventh is the motor nerve of the muscles of expression. 
Complete paralysis of the fifth nerve results in the loss of sensibility 
of one side of the face, of the mucous membrane of the mouth, the 
conjunctival membrane, the anterior portions of the tongue, with 
the muscles of mastication upon the affected side. The external 
manifestations are not so pronounced as in paralysis of the seventh 
nerve, because the resulting deformity is not so great. There is a 
loss of the special sense of taste, and sensation is absent. But i/ 



I56 ORAL PATHOLOGY AND PRACTICE. 

the affection is unilateral, mastication may be carried on by the use 
of the muscles upon the sound side. The tongue and buccal tissues 
upon the paralyzed side are frequently bitten and lacerated in 
the act of taking food, sometimes seriously, because the muscles 
are unable to keep themselves from getting between the teeth, and 
sensation being gone the patient is unaware of the injuries that are 
being received. Such paralysis may be induced by long exposure 
of the face to cold or a keen wind. 

Paralysis of the seventh cranial nerve is perhaps not so com- 
mon as that of the fifth, but it is much more readily observed, as it 
results in serious deformity. With the loss of function in the nerve 
all expression in the affected side is lost. In speaking or smiling 
the mouth is drawn toward the sound side through the loss of con- 
tractile power in the muscles of the affected side. The contractility 
of the orbicularis oculi being absent, the patient is unable to close 
the eye or to wink. The secretions of the lacrymal gland are not 
diffused over the conjunctiva owing to the loss of function in the 
orbicularis, and there is a more or less constant overflow of tears 
upon the cheek. The saliva dribbles from the angle of the mouth, 
and the pronunciation of certain letters of the alphabet is interfered 
with. 

Paralysis of the seventh is perhaps most often caused by intra- 
cranial disease. These cases will properly fall within the province 
of the general practitioner. But it may be the result of injury. 
The extraction of a considerable number of teeth at one time may 
produce a shock that will cause spasms of the muscles of mastica- 
tion, or even inhibition of function and paralysis, with jaw drop. 
The spasm may be clonic (paroxysmal) or tonic (continuous). 

The symptoms are too pronounced to be mistaken. There will 
be a drawing of the muscles of the face, due to their entire relaxa- 
tion, with a loss of mobility. The eye remains staringly open, and 
a smile is observable on one side alone. All expression upon the 
affected side is lost and the muscles are in a state of tonic relaxa- 
tion. This will be observed by the operator before the patient 
becomes aware of the lesion. If it is of a clonic character he may 
by gentle manipulation of the tissues relieve the spasm, or tem- 
porary paralysis, and within a few moments have the satisfaction of 
seeing the muscles regain their tone. Of course he will remove 
the hand-glass from the reach of the patient to prevent the unneces- 



FACIAL PARALYSIS. 157 

sary alarm and nervousness which discovery would cause, and 
which would only tend to aggravate the condition. Should the 
injury be more lasting in its character and assume a tonic form, the 
dentist should explain to the patient the probably temporary nature 
of the lesion and commence the proper treatment for relief of the 
condition. 

One of the most effectual remedies for this condition is elec- 
tricity. The faradic or induced current should ordinarily be used, 
and it must be gentle at the outset, nor should it be continued 
too long. The cathode or negative pole should be placed over the 
cerebellum, and the anode or positive electrode carried gently over 
the points of distribution of the affected nerve. Occasionally the 
poles may be changed, and if it is desired to stimulate the facial 
nerve alone, the stationary electrode may be placed immediately in 
front of the external auditory meatus, while the other is moved 
successively over the various terminal branches. This treatment,, 
if found beneficial, may be repeated every day, provided the cur- 
rent is not too strong and not too long continued. At the outset 
it should not be used so often. 

If the disorder has its seat in the ganglia, the magneto-electric 
interrupted current may sometimes be used with good effect, but it 
should be employed with caution, because it may still further tend 
to the inhibition of the neural currents in exhausted trunks or 
branches. 

Massage of paralytic muscles, if mild and properly applied, will 
be of great benefit in many cases. The facial muscles may be gently 
manipulated with the balls of the fingers, and rubbed in the direc- 
tion of their fibers with the palm of the hand. 

The hygienic condition must, of course, be carefully looked 
after, and out-of-door exercise with nourishing food directed. 
Vegetable tonics may be prescribed if indicated, and quiet and rest 
ordered. If the paralysis is the result of any trauma, such as the 
extraction of teeth, the wounds must be carefully examined to see 
if there are any loose fragments of alveolus or bone left, and all 
possibly irritating projections and spiculae should be removed. An 
aseptic condition must be maintained, and soothing applications 
applied. With these precautions, unless the lesion is very great, a 
gradual return of functional activity may be anticipated. 



T58 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XXXIV. 

SYMPATHETIC DISTURBANCES. 

The nervous system of the body holds all the various organs and 
tissues in correlation with each other, and secures harmonious 
functional action between them. Every organ works, not alone 
for itself, but for all the rest. There is but one heart to carry on 
the vascular circulation for all the tissues, but one digestive tract to 
provide nutrition for all, and but one pulmonary organ to furnish 
the necessary supply of oxygen. Hence the mutual interdepend- 
ence is complete, and no tissue or organ can be properly studied 
aside from its relation to the others. No oral physician, or dentist, 
is equipped for the practice of his specialty until he can show that 
he has made himself acquainted with the functions of other organs, 
and has learned their possible reflex agency upon those with whose 
care he is especially charged. A fair knowledge of the anatomy 
and the physiological function of every tissue in the body is essen- 
tial to the dentist as well as to the general practitioner, and with- 
out the basal facts upon which all curative measures must be 
founded he is as unfitted for his vocation as would be any other 
man who professes to practice any. branch of the healing art. Any 
disordered condition of one organ affects to a greater or less degree 
all the others. The sympathy may not be as active in one case as 
in some others, but it is as certain. The dependence of one tissue 
or organ upon another may not be as complete or entire as that of 
others, or as may be the reciprocal reliance, but it surely exists. 
Proper functional activity of the brain may for some years be 
more disturbed by indigestion than would ensue to the stomach if 
the converse were the case, but no physiologist would assert that 
digestion could be properly and fully performed in cerebral conges- 
tion. The gravid uterus of the female will be more deranged by 
toothache than the teeth will be disturbed by metritis, but each 
reacts upon the other to the extent of its susceptibility, and their 
mutual relations cannot be lost to sight. 

The organs disturbed by diseases of the teeth and the oral 
tissues will be those to which they bear the closest relation. It is 
well known that the teeth sympathize with each other to such an 
•extent that it is sometimes difficult to determine which one, and 



SYMPATHETIC DISTURBANCES. 1 59 

sometimes which jaw, is affected. Otitis media may exhibit itself 
as toothache, while on the other hand pains in the middle ear are 
very often mere reflexes of odontalgia. The eye sympathizes with 
the teeth to such an extent as sometimes to exhibit a profuse 
lacrymal discharge as the accompaniment of toothache, and alveo- 
lar abscess may be diagnosed by the condition of the pulse. The 
otologist especially should be on good terms with the dentist, for 
mutual consultation is frequently desirable, owing to the intimate 
relations of the organs concerned. 

But the reflex disturbances which most concern both practi- 
tioner and patient are the possible complications of pregnancy. 
Women have long been taught that the relations between the teeth 
and the impregnated uterus are so intimate that each must 
vicariously suffer for the other. "For every child a tooth," was a 
proverb long before the period of modern dentistry. That extrac- 
tion is very liable to be followed by premature delivery is a part of 
the creed of every expectant mother. The impression resting in 
the minds of too many dentists that temporary disturbances may, 
within a short time, exhibit themselves in a softened or changed 
condition of the tooth structure, is perhaps responsible for a part 
of the general belief that the teeth decay to a much greater extent 
than usual during pregnancy. 

It should be remembered that nutritive changes in the dentine 
are exceedingly slow, while it is not unreservedly admitted that they 
take place at all in enamel. Hence, while functional disturbances 
in the teeth are quick to manifest themselves in allied tissues, the 
reverse is not the case. A continued fever may cause a great waste 
in many tissues, but it cannot in the teeth, because there are in 
them no absorbents, no lymph system. There is no active circula- 
tion in either dentine or enamel, through which progressive or 
retrogressive changes may be readily and quickly wrought. The 
supposed divergence of the nutrient currents from the teeth to the 
growing child must, then, be largely imaginary, and there can be 
no sudden breaking down of these organs during pregnancy. 

And yet the general impression that the teeth decay more at 
that time than any other doubtless has some basis upon which to 
rest. One explanation may be found in the fact that at such times 
the pregnant woman has something else to take up her whole atten- 
tion, and often intermits the care that she is accustomed to give 



l60 ORAL PATHOLOGY AND PRACTICE. 

her teeth. Food is suffered to remain upon and between them, 
and fermentation does its perfect work. The pregnant woman 
sometimes has perverted or unnatural appetites, and takes into her 
mouth deleterious substances. Mineral tonics are frequently pre- 
scribed for her, and these may bring about destructive results. 
But there is little doubt that the fact that at least a year passes in 
which she is usually without the dentist's help is the principal factor 
in the result attained. Poor people, who never care for their teeth, 
find little difference between the period of gestation and any other. 

The fear that a visit to the dentist must result disastrously is 
a mistaken apprehension. It is the true office of the oral practi- 
tioner to relieve pain, and not to cause it. Every woman who finds 
herself pregnant should visit her dentist, if he is a competent man, 
should tell him her condition, and place herself in his hands for 
such measures as are necessary. He will take special care to avoid 
giving her pain at such a time, not because it would always be 
immediately hazardous, but from the necessity for preserving her 
mental and nervous equilibrium to as great an extent as is possible. 
Jf there are cavities of decay that would be likely to bring about 
complications before the time for her delivery, they should be filled, 
usually with plastic materials. If there are troublesome teeth, so 
badly diseased as to forbid conservative measures, they should be 
promptly extracted. If the administration of a general anesthetic 
is essential, she should be referred to her medical attendant. If 
from the performance of any such necessary operation, when care- 
fully and skillfully done, any ultimate harm has ever occurred, it 
has not been made a matter of record, and the world is in ignorance 
of it. It should not be forgotten that the pregnant female is usually 
in a state of exalted nervous sensibility, but that does not neces- 
sarily imply that all operations upon the teeth are inhibited. 

That there is more toothache during gestation than at other 
times may be quite true, but there are often sympathetic disturb- 
ances, without real tooth lesions, that have their origin in the 
disordered nervous condition. Concerning the nutrition of the 
teeth of both mother and child, and the prevailing belief that these 
can be governed by any specially regulated diet, another chapter 
will have something to say. 



DISEASES OF TH^ MAXILLARY SINUS. l6l 

CHAPTER XXXV. 
DISEASES OF THE MAXILLARY SINUS. 

The position and relations of the Antrum of Highmore, or the 
Maxillary Sinus, make it peculiarly liable to disorders of a catarrhal 
nature. There doubtless exist many more such than are recognized 
by oral physicians. The sinus is a cavity within the superior 
maxilla, connected by a small opening with the air passages of 
the nose. It allows proper contour of the face without the weight 
of bone that would be the consequence of solidity. It also makes 
the nutriment of the bone more easy, and obviates any necessity 
for a large medullary portion. But its principal utility is in giving 
resonance to the voice. All musical instruments have a hollow 
chamber of some kind, to increase the reverberations and reflect 
the vibrations of the air. The perfection of the instrument and its 
quality and volume of tone depend very largely upon the particular 
form of this reverberatory chamber. Many years of experiment 
have not been able to devise any beneficial modification of the 
peculiar shape of the body of the violin, as it was fashioned by 
Guarnerius, more than two hundred years ago. Any departure 
from that model, whether accidental or intentional, has been found 
to change the character of the vibrations and impair the tone of 
the instrument. 

The antrum is the principal sounding-chamber of the human 
voice, and the wide variations in the character of the tones produced 
are due in a large degree to the size, shape, and condition of the 
cavity. The howling monkey, whose voice can be heard at night 
for several miles, has an additional osseous chamber to reinforce 
the reverberations of the antrum. (See Fig. 42.) All are aware 
of the peculiar hard, metallic, unmusical tone that is communicated 
to the voice in cases of empyema of the antrum, or in atresia of 
the communicating sinus. 

The size and shape of the antrum in different individuals vary 
as greatly as do the characteristics of the voice. In some it is large, 
and occupies the whole center of the bone. The two antra in the 
maxillae have even been known to be a continuous cavity, united 
by a communicating opening across the symphysis. Usually, how- 



j52 oral pathology and practice. 

ever, its anterior limit is the canine fossa. It is sometimes par- 
tially divided into a number of chambers by septa passing across 
its floors. (See Fig. 43.) 

The opening by which it communicates with the air passages is 
at the point of junction of the ethmoid and palate bones and the 
turbinated process of the superior maxilla. This is usually at or 
very near its highest point. Dr. M. H. Cryer, of Philadelphia, has, 
by his dissections and studies of the cranial bones, added largely 



Fig. 42. 



mm^,,. 







Showing the Resonant Chamber Attached to the Larynx in the Howling Monkey. 

to our knowledge of the structure and configuration of this cavity ; 
and Dr. Thomas Fillebrown, of Boston, has given us yet further 
illumination. 

The commencement of the formation of this cavity is not until 
early childhood has been passed. Hence antral disorders are un- 
known in infancy, because there is then no maxillary sinus to 
become diseased. 

The mucous membrane lining the antrum is continuous with 
the Schneiderian, or that covering the bones and cartilage of the 



DISEASES OF THE MAXILLARY SINUS. 



163 



nasal cavity. It will therefore be liable to the same diseases and 
be materially affected by the condition of the air passages. In- 
flammations and degenerations of the Schneiderian membrane, by 
mere continuity may be communicated to the antrum, and a nasal 
catarrh may induce a chronic antral disorder. This will be the 
most fruitful source of the degenerated conditions so often present, 
and if what has frequently been asserted is true, that in the northern 
and eastern parts of the United States the person who is entirely 
free from catarrhal troubles is an exception, it must necessarily 

Fig. 4.3. 




Vertical Section through the Skull. 
a, Frontal sinus ; 3, A wire probe thrust into the infundibulum ; c and <?, Membranous 
septa extending across the antra ; d, The oral cavity. 



follow that most of the residents of those sections have disor- 
dered or inflamed antra, and this may account for the nasal tone 
said to be characteristic of their voices. 

The roots of decayed and devitalized teeth may sometimes 
penetrate the floor of this cavity and become points of irritation and 
of infection. It does not seem probable that any healthy root can 
actually pierce the floor. The very conditions of the formation of 
the apex demand its investment by the pericementum, and that 
being a double membrane its functional activity implies a septum 



164 ORAL PATHOLOGY AND PRACTICE. 

of bone upon its exterior surface. Accordingly, in the examina- 
tion of antra it is found that the apex of the root of a premolar or 
molar tooth that might otherwise be within the cavity is covered 
with a thin septum of bone that forms a distinct eminence upon the 
floor, and no tooth that reaches the level of the antral floor is with- 
out this. When, however, there is a devitalization of the pulp, 
with a consequent pericemental inflammation at the apex, the 
nature of that affection implies an absorption of the bone that forms 
the septum; and then the end of the tooth might be within the 
antral walls, perhaps perforating the mucous membrane. Under 
such circumstances the apical pericementum would be lost, and the 
root to that extent denuded. 

If an abscess forms at the apex, it may discharge into the sinus, 
hut such a condition will not be likely to exist, because there must be 
investing tissues capable of affording a continuous supply of plastic 
lymph to form the basis of the pus discharge. As this would not 
be the case when the apex of the root actually lay within the 
antrum, penetrating the lining, a chronic abscess discharging into 
the antrum is not probable. The projecting root, however, could 
undoubtedly prove a continuous source of irritation to the lining 
membrane, and thus be the cause of a persistent inflammation, 
which in due process of time would induce a condition of degenera- 
tion of the mucous follicles, with ultimate breaking down of their 
structure. In this manner the roots of dead teeth may undoubtedly 
be the cause of actual empyema. 

Traumatism is, probably, more frequently than many persons 
are aware of, the origin of actual degenerations. Teeth are too 
often extracted with a degree of violence that would never be con- 
doned in the general surgeon. The fact that the alveolar walls are 
exceedingly vascular, and that injuries are healed more readily 
than in any other osseous tissue, alone saves the patients of many 
harsh dentists from most serious consequences. There are more 
fractures of alveolar walls, even to the depth of the maxillary sinus, 
than most people would imagine. There are few practitioners who 
have not seen cases, either in their own practice or that of others, 
in which a part or the whole of the septa of the molar teeth was 
removed, making a considerable opening into the antrum. 

The presence of foreign substances sometimes induces a dis- 
eased condition. Into a cavity, accidentally made, may penetrate 



DISEASES OF THE MAXILLARY SINUS. 



165 



some extraneous matter that will remain a source of irritation, or 
the root of a tooth may be forced into a cavity in extraction, and 
as long as this remains the degeneration will be kept up. 

It has been demonstrated that the infundibulum, through 
which the frontal sinus discharges its secretions, in a considerable 
number of instances at least, opens into the apex of the antrum 
instead of into the meatus of the nose. Normally, the opening is 

Fig. 44. 




Vertical Section through the Skull Immediately Posterior to that Shown in 

Fig. 43. 
a a 1 , Wire probes thrust through the natural apertures into the antrum; b, Nasal fossa 
showing turbinated bones ; c, Oral cavity. 

separated from the mouth of the infundibulum by such a thin 
septum that it is readily broken down by any diseased condition. 
In such instances any vicious secretions from the frontal sinus 
would form the initial point for degenerations in the antrum. (See 
Fig. 44.) 

Whatever their source of origin, the usual phenomena pre- 
sented by antral diseases are those of disordered mucous membrane. 
The probable steps in the degenerative process are, first, a 



1 66 ORAL PATHOLOGY AND PRACTICE. 

hyperemia, to be succeeded by congestion and suppression of the 
mucous secretion. Then follows an active state of inflammation, 
with degeneration of the mucoid follicles, and perhaps a profuse 
watery discharge. This may continue for a time, when, if the irri- 
tation is continued, further degeneration takes place, with final 
breaking down or ulceration of the surfaces. The mucous mem- 
brane thus destroyed, and the periosteum devitalized, there is no 
longer normal nutrition for the bone, and a progressive caries of 
this tissue, or even necrosis, with a profuse discharge of pus, will be 

the consequence. 

Symptomatology. 

The symptoms attending the early stages of catarrh of the 
antrum are not very marked or distinctive. There will be a feeling 
of dryness, with its characteristic pain in the antral region, and 
possible pressure. The latter symptom, however, more distinc- 
tively belongs to a later period. The general phenomena are those 
of catarrh of the air passages. 

These are perhaps succeeded by profuse watery secretions, 
which may quite fill the antral cavity and produce that feeling of 
pressure and the changes of voice that are so often observed in 
acute coryza. This will pass away with the other prodromata of 
empyema. 

Finally, the repeated attacks of the acute inflammatory process 
are succeeded by a continuous, chronic condition, and function is 
permanently impaired. This leads to structural degenerations in 
the mucous follicles themselves; they break down and an ulcer- 
ative surface succeeds, and thus an empyema is established. Pus 
may be formed in such quantities that the antrum is filled, with 
complete atresia of the natural opening, and a distressing distention 
is the result. 

The feeling of pressure under such conditions will be severe. 
There will be the usual septic fever, and the superincumbent tis- 
sues will be hot and irritable. If this breaking down of the tissue 
and the formation of pus continues, there will be dilatation and pro- 
trusion of the antral walls at their weakest point. This may be in 
the orbital region, and the eye may be actually forced partly out of 
its socket. It may be at the basal walls, in which case the pro- 
trusion will be above the roots of the teeth; or it may be at the 
palatal processes of the maxillary, and the protuberance be into the 
oral cavity. 



TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 1 67 

The general symptoms will be nearly the same if the origin 
of the disorder is other than that of nasal catarrh. If the frontal 
sinus is diseased, and its depraved contents are discharged into the 
antrum through a misdirected infundibulum, the prodromata will 
be more brief in their course, but the pathological changes will not 
materially differ. The same may be said of the presence of foreign 
substances in the sinus. The character of the changes will be those 
that are usual in inflammations of mucoid surfaces. 



CHAPTER XXXVI. 

TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 

The prognosis is usually good, provided all sources of irritation 
can be removed, and, as in all inflammatory processes, the first 
attention should be paid to this point. If the trouble is taken in its 
early stages of simple catarrhal inflammation, the usual remedies 
for that affection should be employed. Nasal douches of 
erethymol, listerine, or borolyptol, diluted with from three to five 
volumes of water, may be frequently used for irrigating the nasal 
mucous membrane. If these cause pain, a little cocain may be 
added. For the ordinary colds, that seem likely to run a chronic 
course, with first a dry, heated condition of the mucous membrane, 
followed by a muco-purulent discharge, the following may be used : 

B — Borolyptol, oj ; 

Cocainas hydrochlor., gr. ij ; 

Aquae dest., oiij. 
Sig. — Use as an irrigating douche. 

In the acute stage of coryza the following will be found useful : 

3 — Acid, carbolici, 5^ ; 

Alcoholis, 3ij ; 

Aq. ammonise fort., 3j; 

Listerine, oiij. 

Sig. — Pour half a teaspoonful into a cone made of blotting-paper and 
inhale. 

In addition, for the relief of the antral congestion, a saline 
cathartic may be given, its operation to be followed, at bed-time by 
one-sixth to a quarter of a grain of sulphate of morphia, dissolved 
in an ounce of acetate of ammonia liquor. 

With relief for the catarrhal inflammation the antral complica- 



1 68 ORAL PATHOLOGY AND PRACTICE. 

tion will pass away. But if there is any filling up of the sinus, 
either hydromatous or empyemic, it must be opened. This is 
accomplished by penetrating the walls with a trocar. To obtain 
perfect drainage it is absolutely essential that this be done at the 
correct point, otherwise some of the cavity will continue to be 
bathed in the vitiated fluid. Usually the lowest depression is found 
just anterior to the first molar tooth, but this is by no means 
universally the case. Sometimes the antral cavity does not reach 
anterior to this, and occasionally it lies considerably farther for- 
ward. If the thumb and finger are made to grasp the alveolar and 
palatal processes, and the oral region thus carefully examined, one 
may be able to determine the point at which the divergence of the 
walls marks the beginning of the cavity. 

If the first permanent molar has been removed, the best place 
for making an opening will be at that point. If it be much decayed 
it will be wise to extract it and drill or puncture through the socket 
of its lingual root, as the floor of the antrum is lower on the lingual 
than on the buccal side. Care must be taken to avoid following too 
far in the direction of the root if it diverge much from the others. 
The drill, or trocar, should be pointed in the proper line. The best 
instrument is a twist drill in the dental engine. The cavity once 
reached, the aperture should be expanded with a reamer until it is 
at least as large as a common lead pencil. An opening less than 
this will be likely to become closed. It is not usually a formidable 
operation, or one attended with a great deal of pain, but in most 
instances it will be advisable to administer an anesthetic. 

The opening once made, a little time should be given for its 
drainage, when it may be washed out with tepid water in which 
a little salt has been dissolved, thrown into the cavity with a 
syringe. This may be repeated until the cavity is quite clean, when 
a disinfectant, like peroxide of hydrogen or electrozone, warmed 
to blood temperature, may be substituted. Care should be taken* 
to dilute it if peroxide of hydrogen is used, for if much pus remains, 
and it be injected pure, or nearly so, violent and painful foaming 
may be the result. 

If the opening is of sufficient caliber and made at the lowest 
point very little treatment will, in cases uncomplicated with dis- 
charges from the frontal sinus or foreign growths or substances, be 
demanded. The antrum should be thoroughly washed out with 



TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 109' 

tepid water before medicinal agents are introduced. A disinfectant 
simply decomposes septic matter, and there is necessarily nothing 
therapeutic in its nature aside from this. It is better to wash out 
the pus than to decompose it, for its elimination will be more per- 
fect and more readily brought about, provided the opening is com- 
pletely patulous. 

The cavity having been cleansed, the next step will be to secure 
continual drainage. For this purpose the insertion of a drainage 
tube has been recommended, but this, it is believed, will seldom be 
found necessary, and there are conclusive reasons for its rejection, 
if that be possible. 

The drainage tube that has usually been employed is of metal,, 
and is attached to some convenient tooth by a clasp. It is very diffi- 
cult to retain in position one of any other kind, because adhesive 
plaster bandages, and the methods by which such are usually held, 
are inadmissible in the mouth. A metal drainage tube must of 
necessity act as a continual irritant and become a focus of inflam- 
mation and of infection. It is almost impossible accurately to 
adjust its length, and if it should once be perfectly adapted it will 
not remain so. If the upper end projects above the floor of the 
antrum it will not afford perfect drainage, and if it does not it will 
fill and become stopped with granulations more readily than an 
opening without such a tube, because its irritant presence will 
stimulate hyperplastic growths. 

It will seldom be the case that a drainage tube will be needed 
if the opening is sufficient. Should the mouth of it not remain 
patulous, the granulations should be cauterized or cut away. This 
will be better for the disorder than to allow them to grow about a 
drainage tube. If the orifice is kept dehiscent, open and gaping,, 
the drainage will remain perfect, and the diseased condition will 
not be perpetuated by retention and further degeneration of the 
septic product, even for an hour. 

Tents and plugs for the perforation should be avoided. They 
are an irritation, retaining within the antrum the septic products 
that should be removed or allowed to escape as soon as formed. 
Even a moment's restraint is evil in its tendency. The sole excuse 
for their employment is that they prevent the entrance of food, 
saliva, etc., from the mouth. There is no cause for anxiety from 
this source, for saliva will not enter against the force of gravitation,. 



170 ORAL PATHOLOGY AND PRACTICE. 

while food and debris can only penetrate when forced in, and they 
are usually spontaneously eliminated before fermentation can take 
place. But even if there is a liability to the intrusion of foreign 
matter through an unstopped orifice, the possible resulting injury 
could not be as great as that arising from an impeded drainage. If 
the natural foramen of the antrum is closed the artificial opening 
must be kept unstopped, because communication with the outside 
air is a necessity. As well might one seal up the drum-hole as 
entirely to close the antrum, which, as has already been said, is a 
reverberatory chamber. 

The employment of tents and plugs has resulted in very serious 
injury at times. It will doubtless have been found by most oral 
surgeons who have had a considerable experience in the treatment 
of antral disorders, that the most obstinate and incurable cases were 
those in which a comparatively small aperture had been made, with 
the subsequent attempt to keep it open by tents, distenders, and 
drainage tubes. It has become the common usage of those who 
have acquired skill by extensive practice in these cases, first of all, 
carefully to explore the antrum for lost plugs and dressings, or 
parts of such, which are certain to perpetuate the disease. Any 
oral surgeon can call to mind more than one instance of this. The 
author has never met with a case of persistent antral degeneration, 
in which it was possible to remove the source of irritation, which 
was not healed with comparative readiness if drainage was left free 
and unimpeded. He has frequently met instances in which no 
relief was obtained until a dressing or other foreign substance that 
had lodged in some depression in the floor had been found and 
removed. In one case it was a piece of iodoform gauze more than 
six inches in length. 

Perfect drainage having been secured, there are comparatively 
few cases that will demand anything more. The use of the drastic 
and irritating remedies and solutions that are so frequently injected 
is to be avoided. Cleanliness once assured, the vis medicatrix 
naturae will usually do the rest. A considerable number of in- 
stances from daily practice might here be cited, in which a profuse, 
long-continued, and exhausting empyemic discharge was entirely 
cured by a proper operation, the permanent removal of all tubes, 
plugs, tents and dressings, and a thorough washing out and disin- 
fection of the sinus. 



TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 171 

The irregularities in the shape of some antra insure the in- 
definite continuance of the septic state unless some further surgical 
interference than the mere perforation of the floor is provided. 

Occasionally septa will be found crossing the cavity, and dividing 
it into partially separate chambers. Depressions in the base will 
be encountered, which will retain septic matter. If the opening 
has been made sufficiently large, a bent silver probe may be used 
to explore for any laminae and dividing walls, and for intrusive 
foreign substances. When their nature will permit, any septa 
should be broken down, and when this is not practicable the patient 
should be directed occasionally to incline the head in such a man- 
ner that any retained fluids may flow out toward the drainage open- 
ing. Care should also be used frequently to wash out such depres- 
sions and partial chambers, and to keep them thoroughly disin- 
fected. (See Fig. 43.) 

The author has in some instances found it impracticable to 
make an opening sufficient for all this work through the floor of the 
antrum, and has broken down the external walls until the end of 
the finger c»uld be introduced for exploratory purposes, Such an 
aperture gives entire access to every part of the sinus, and enables 
the operator to determine the presence of necrosed conditions, and 
to extirpate dead tissue, if it be not of too great proportions. 
General surgeons usually open through the alveolar walls just 
posterior to the canine fossa, claiming that an orifice sufficient in 
size cannot well be obtained at any other point. 

There will be instances in which, from a general atonic or 
anemic state, some cachectic condition, or special degeneration like 
necrosis, there is not a speedy return to health. The inflammation 
may assume a low, subacute, or chronic stage, and the indolent 
tissues refuse to respond to the treatment indicated. In such cases 
more rigorous measures must be inaugurated. After disinfection 
a solution of three to five grains of chloride of zinc to the ounce of 
water may be injected, and made to reach every part. This will 
act as an antiseptic and a stimulating astringent, and probably 
bring about an altered condition. If it be insufficient, it may be 
used in still stronger proportions, the production of painful and 
irritating symptoms being the guide for its limitation. 

If there is pain, it may be treated by an injection of dilute 
wine of opium. In case of a profuse discharge from an ulcerated 



172 ORAL PATHOLOGY AND PRACTICE. 

mucous membrane, a solution of zinc sulphate, one dram to the 
ounce of water, may be used. When there is a great deal of fetor 
a solution of potassium permanganate, ten grains to the ounce 
of water, will be found useful. Carbolized solutions may be 
employed, the avowed aim being to produce a temporary aggrava- 
tion of the inflammatory symptoms, or to change the chronic con- 
dition to one that is more acute. 

If the degenerative process shall have proceeded so far as to 
involve the bony walls, an operation for the removal of the dead 
tissue will he necessary. These necrosed conditions may be de- 
tected not only by the amount and character of the pus, but the 
condition can be verified by careful explorations with the probe. 
Whenever the symptoms lead to the conclusion that depraved secre- 
tions from the frontal sinus are discharged into the antrum, the 
opening should be kept patulous and the attention directed toward 
the other cavity that is the source of the disease. 

An opening through the bone of considerable size, that has 
served for the drainage of pus, will not always entirely close. This 
will not materially matter, because there will usually be a formation 
of soft tissue and mucous membrane over it that will be sufficient 
for the exclusion of foreign matter. Even if this is not accom- 
plished little inconvenience is experienced, provided nothing is 
kept in it that can retain food until it ferments within the sinus. 
It will not be in a worse condition than are the nasal passages in 
cases of cleft palate. It may be necessary periodically to wash out 
the antrum, but this can readily and easily be accomplished. 



CHAPTER XXXVII. 

DISEASES OF THE FRONTAL SINUS. 

As this cavity is much smaller than that of the antrum, and as 
sometimes it is practically absent, its pathological complications are 
less in number and of smaller import. It is another of the openings 
connected with the air passages, and the reasons for its existence 
are identical, though of less importance, than in the case of the 
maxillary sinus. As in the case of all other open cavities it is lined 
with mucous membrane, and its diseases will be the same as those 



DISEASES OF THE FRONTAL SIXUS. 



173 



of the antrum, except as they are modified by the different environ- 
ments. It is probable that they seldom originate in the sinus itself. 
Inflammations and degenerations of the lining membrane will 
comprise the most of these, and, while the presence of foreign sub- 
stances may be eliminated from the list of causes inducing them, 
the pathological changes will be so nearly analogous that a 
recapitulation of them is unnecessary. In edemas and empyemas 
the discharge is through the infundibulum that penetrates the 
ethmoid, and into the middle meatus of the nose. (See Fig. 45.) 

Fig. 45. 




Vertical Section of the Skull. 
a, The inferior and middle turbinated processes, b. Posterior part of the antral or maxil- 
lary sinus, c, The infundibulum of the ethmoid. 

The diagnosis of these conditions must be through the tracing of 
this vitiated matter to its source, and from the sense of fullness 
and pressure that will inevitably be felt in the supra-orbital region. 
Local treatment will be impossible unless an opening is made, 
which will be from the lower border of the bone, through the 
supra-orbital prominence or ridge into the cavity, where it may be 
treated as in the case of the antrum. But this is a very unusual 
operation, and seldom called for except in cases of atresia of the 



174 ORAL PATHOLOGY AND PRACTICE. 

discharging duct or canal, or when the discharge has induced a 
degenerated condition of the infundibulum, or is flowing into the 
maxillary sinus. 

That these latter conditions may exist and may induce serious 
complications, the following case in the practice of Prof. Truman 
W. Brophy amply demonstrates. Miss A. had for some years 
suffered from what was pronounced antral disease. Five opera- 
tions for its relief had been made by different surgeons, most of 
them consisting of the usual opening and flushing of the sinus with 
antiseptic and stimulating solutions. It was now determined to 
explore the cavity more completely than had yet been done, and to 
this end the maxillary walls above the roots of the teeth were 
removed until the finger could be introduced. No foreign sub- 
stance or growth was found, and the cavity was temporarily packed 
with antiseptic gauze. At a subsequent visit this was removed and 
the antrum critically examined. Near the apex purulent matter 
from some superior source was observed to percolate into the sinus. 
The connection of the frontal sinus with the diseased condition 
had not previously been suspected, but in the light of the then 
newly published observations of Dr. Cryer it was at once apparent. 
The infundibulum was discharging pus into the antrum, and the 
seat of the disease was either in the frontal sinus or in the ethmoid, 
and a further operation was at once determined upon. At the 
proper time the supra-orbital tissues were divided, the filaments 
of the supra-orbital nerve dissected out and an opening made into 
the frontal sinus, from which pus at once welled up. The opening 
was now extended the whole length of the sinus, until a probe 
could be thrust down through the infundibulum for a considerable 
distance, when its point was found in the maxillary sinus. Careful 
probing now demonstrated that the cells of the ethmoid were in a 
degenerated condition, and that the connecting passage was for a 
part of its length devoid of its membranous lining. With properly 
shaped burs in the surgical engine the incision was carried along 
the course of the infundibulum until the center of the nasal bone 
was reached. A considerable opening was made in this bone, the 
degenerated portions of the ethmoid were removed, the surfaces 
of the discharging canal freshened and its mouth made to open into 
the nasal meatus instead of into the antrum. A drainage tube was 
now inserted into the frontal sinus, through which the whole terri- 



CYSTS AND THEIR TREATMENT. 1 75 

tory could be flushed, and the wound was c 1 osed about it. The dis- 
charge was for some time very profuse, but continued antiseptic 
treatment finally resulted in a complete cure. When the infundib- 
ulum was made to discharge into the nasal cavity the trouble in. 
the antrum was at once relieved, and never returned, thus conclu- 
sively proving that the source of disease was not in this sinus, 
which was only secondarily affected from the frontal sinus. 



CHAPTER XXXVIII. 
CYSTS AND THEIR TREATMENT. 

A Cyst is a tumor containing a cavity or cavities filled with 
fluid or semi-fluid contents. In one ?ense, it is nature's method of 
isolating from the tissues any foreign or irritating matter. It is 
the only way in which extraneous substances can be permitted 
permanently to remain in the animal economy. 

When cysts consist of a single chamber they are simple, and 
when divided by membranous septa multilocular. Should they 
contain teeth they are called dentigerous cysts. (See Fig. 46.) 

A cyst may also be the result of the stoppage of some duct, 
and the consequent retention of the secretion of the gland of which 
it was the discharging canal ; or it may be the mere collecting of a 
watery fluid in a previously existing serous cavity, the outcome of 
functional disturbance. 

The most common and at the same time the most benign and 
innocent of these tumors is the sebaceous cyst, which, as its name 
indicates, is filled with fatty matter. They vary in size from that 
of a millet seed to that of an orange, and are most frequently con- 
nected with the sebaceous glands of the skin. 

A cyst consists of a membranous pouch, without an opening, 
that envelopes the alien substance when such exists, and separates 
it from the tissues. In like manner a colony of bees, when some 
animal or offensive substance which they are unable to expel gains 
entrance to the hive, seal it up and segregate it by covering it with 
an impenetrable coating of wax, within which it loses its repulsive- 
ness. A cyst is filled with a fluid in which the offending matter 



176 



ORAL PATHOLOGY AND PRACTICE. 



floats or is contained, thus preventing its immediate contact even 
with the cyst walls. 

Cysts are developed in natural cavities of the body, or within 
the substance of an organ. They cause a distention that with the 
continual gathering of the cystic fluid and the constant growth of 
the cyst sometimes tecomes of enormous proportions. It is only 
through their expansion that they assume any dangerous character, 
for they do not otherwise cause functional disturbances. They 

Fig. 46. 




* x%«/ • 'LSI /* ? > ^ X ' A 



Dentigerous Cyst in a Young Horse, containing Nearly a Quart of Denticles. 
a, Mass attached to the bone, b and d l , Loose pieces. (From a specimen in Buffalo 
College Museum.) 

may readily be distinguished, in most instances, through this 
peculiarity, and through their slow formation and the entire lack 
of pain that accompanies their growth. 

The methods of distinguishing them from tumors are various. 
If they are accessible, the fluctuation of the fluid contents may 
readily be perceived. Sometimes, when they have existed for a 
long period without materially growing, a parchment-like crackling 
will be felt upon pressure, and it may even be heard with the ear. 



CYSTS AND THEIR TREATMENT. 



177 



It sounds very much like the crepitating sound produced by the 

flexing or bending of bar tin. This is because of the inspissation, 

or thickening into a grumous, clotted mass of the fluid contents, 

through their desiccation, or drying. In deeper cysts it is usually 

advisable positively to determine their character by aspiration, or 

the drawing off of some of the fluid contents, by means of an 

aspirating or hypodermic syringe, and its careful examination. 

This gives a positive method of diagnosis. An exploring needle 

should also be used, to determine the presence of any foreign or 

irritating substance. 

Fig. 47. 




Upper Jaw showing Alveolar Cyst and Other Diseased Conditions the Result of 

Neglect. 
There is recession of the gums and absorption of the alveolar edges due to pyorrhea. 
The central incisor is thrown out of alignment through the formation of an alveolar pocket 
on the disto-lingual aspect. A cyst has formed about the diseased apex of a tooth at a ; there 
is chronic suppuration with alveolar necrosis at b. (From C Rose.) 



Park, whose "Surgery by American Authors" may be ac- 
cepted as the most modern expression of surgical pathological 
knowledge, divides these ordinarily benign tumors into four 
classes: 

1. Retention Cysts. These imply a previously existing cavity, 
whose outlet is stopped up, and whose contents consequently accumulate 
and perhaps degenerate. This class will of course include those oral 
cysts which arise from an obstruction of the ducts of the salivary 
gland. 

13 



I78 ORAL PATHOLOGY AND PRACTICE. 

2. Tubulo-Cysts. These are dilatations of certain functionless 
ducts in other parts of the body. They are largely developmental in 
their origin. 

3. Hydrocele. This, as its name indicates, is a collection of 
watery fluid in some serous cavity > one which has no discharging duct 
and no opening of any kind. Hydroceles are apt to be of congenital 
origin, and are most frequently found in the region of the neck. 

4. Glandular Cysts. These growths are formed by the dilata- 
tion of certain glands. They may usually be classed as retention 
cysts, for the enlargement is most commonly induced by a stop- 
page of the ducts. They may, however, occur in connection with 
the ductless glands, and because of this there is a degree of pro- 
priety in distinguishing them from those which arise from the mere 

closing of a duct. 

Fig. 48. 




Calcific, Structureless Mass involving the Roots of a Molar. 
It had invaded and destroyed cementum and dentine. It was as hard and as dense as bone, 
but had none of its structure. (Practice of Dr. A. M. Holmes.) 

Those which are of interest to the oral surgeon or physician 
are the first and last classes, tubulo-cysts and hydroceles not 
being likely to fall under his observation. 

Cysts in and about the oral cavity, are quite frequent, a con- 
siderable proportion of them being caused by calcareous deposits 
within the salivary glands or in their discharging ducts, and the 
subsequent formation of a retention cyst. 

Ranula is a retention cyst, caused by the stoppage of Wharton's 
duct, or one of the mucous glands beneath the tongue. A small cal- 
culus may be formed within the gland, and it will eventually 
become lodged somewhere in the duct, completely stopping it. The 
saliva or mucus is obstructed and forms a cystic pouch or pocket, 
into which more is continually flowing. The watery portion will 



CYSTS AND THEIR TREATMENT. 179 

be lost, and there will remain a thick, jelly-like mass beneath the 
tongue upon one side, which in some instances thrusts that organ 
quite out of the mouth. It assumes a peculiar mottled appearance, 
closely approaching that of a frog's belly, and hence it has received 
the name of ranula, from the Latin rana, a frog. 

Odontocele or Odontoma is another comparatively common form of 
oral encystment. These are caused by the presence of undeveloped 
or misplaced tooth germs. The former term more strictly applies 
to a cystic, and the latter to a degenerate formation, although both 
are due to the same cause and are of the same general character. 
They may appear at any point of the jaws, wherever the undevel- 
oped germ may exist. They are easily diagnosed in most in- 

Fig. 49. 




An Odontome Attached to a Molar Tooth the Crown of which is at 
the Apex of the Calcific Tumor. 

stances, not only by the means already laid down, but by the addi- 
tional fact of there being a missing tooth, and by their location 
where that might naturally be expected to exist. (See Fig. 49.) 

Park, in his ''Surgery by American Authors," says that the 
odontomata are tumors composed of one or more of the dental tis- 
sues, arising either from tooth changes or teeth in process of de- 
velopment. He deprecates the lack of attention which has been 
given to. them in surgical literature, and says that no tumor of the 
jaw, especially in young people, should lead to excision of the jaw 
until it has been fairly demonstrated that it is not one of this form. 

They are divided into — 

1. Epithelial Odontomata, which are provided with a cap- 
sule and present usually a series of cysts separated by their septa, 
containing a mucoid fluid. 



l8o ORAL PATHOLOGY AND PRACTICE. 

2. Follicular Odontomata, more frequently spoken of as 
"Dentigerous Cysts," which arise in connection with permanent 
teeth, especially the molars, and sometimes reach a great size. The 
tumor consists of a wall representing the expanded tooth follicle 
and a cavity containing viscid fluid, with parts of imperfectly de- 
veloped teeth, sometimes loose and in other instances attached. 
They occur not infrequently in the lower animals. 

3. Fibrous Odontomata, which consist of condensed connec- 
tive tissue in a developing follicle and present a tumor which blends 
with the dental papilla at the root and is indistinguishable from it. 
These tumors are common in the ruminants. 

4. Cementoma. This is a tumor fibrous in character whose 
capsule has ossified or calcified, the developing tooth thus becoming 
imbedded in a mass of cementum. These occur frequently in 
horses. 

5. Compound Follicular Odontomata. These contain num- 
bers of masses of cementum resembling small teeth, or perhaps 
composed of the three dental elements. (See Fig. 46.) 

6. Radicular Odontomata. These are tumors of the roots 
which form after the completion of the crown. They consist ex- 
clusively of dentine and cementum, and are rare in man. 

7. Composite Odontomata. These are hard tumors, bearing 
little or no resemblance in shape to normal teeth. They consist of 
a conglomeration of enamel, dentine, and cementum, thus pre- 
senting an abnormal growth of all the elements of the tooth germ. 
They have been found only in man. 

There are other forms of cysts arising from some functional 
disturbance in the smaller glands of the mouth and tongue. They 
belong to the strictly glandular class, and consist of an enlargement 
or dilatation of a mucous gl:.nd. Such an one is frequently found 
just at the tip of the tongue, where lies the so-called Nuhn's gland. 
These cysts, however, may be of the simple retention variety, due to 
a stoppage or closing of the duct of the mucous follicle. Dermoid 
or congenital cysts are also sometimes found in the mouth. 

Sometimes the cystic formation is within the antrum of High- 
more, which it fills with cystic fluid. In this locality it is liable to be 
mistaken for an ordinary edema of that cavity. But after it has 
existed for some time it usually causes an absorption of the walls 
of the antrum, when its true nature is revealed. This will most 



CYSTS AND THEIR TREATMENT. l8l 

often occur at the external extremity of the antral cavity, where 
the alveolar walls are thinnest. At that point, beneath the cheek, 
fluctuation may readily be observed, and the peculiar feeling of the 
cystic fluid may easily be detected. If there is yet any doubt, an 
aspirator needle may be introduced, and a little of the fluid ex- 
tracted. If this is thick and glairy, with perhaps some flocculent 
matter floating in it, the diagnosis will be clear. 

There is a kind of cyst that is of a distinct interest to the dentist, 
vis, the ovarian dermoid. These dermoids are teratomatous growths, 
made up of matter that is developed from the epiblastic layer. 
Hence we find them containing epithelia, skin, hair, sebaceous 
glands, and well-developed teeth. If they should contain bone, 
muscle, or nerve tissue they would not be dermoids, because these 
are of mesoblastic origin. The author has in his possession a der- 
moid ovarian cyst that contains nearly forty teeth, some of them 
deciduous and some permanent, with hair rolled up into a ball and 
nearly two feet long. 

The treatment of cysts is usually quite simple. In most cases 
it is sufficient first to open the cystic tumor and explore it for the 
presence of an irritating agent. This, when discovered, should be 
removed. The contents of the cyst should now be thoroughly 
evacuated, and the cavity washed out with a weak disinfecting 
solution, when the whole may be packed with iodized lint. Granu- 
lations will usually commence and complete the cure. It may be 
desirable to wash out the cavity with a stimulating fluid, and wait 
a little time to see that no undue inflammation succeeds, before the 
iodized lint is used. 

In cysts within the bone, or in the antrum, septa may exist, 
partially dividing the cavity into two or more portions. These 
should usually be broken down, that the diagnosis may be complete. 
This will be found especially true in the maxillary sinus. 

In ranula, it is desirable to remove the obstructing calculus 
and evacuate the cyst without cutting, if it be possible, that the 
course of the duct may not be changed. A little careful manipula- 
tion will not infrequently be effectual in driving the concretion, if 
it is not too large, out through the course of the duct, when the 
contents of the cyst may be removed by means of the aspirator. 
Should the cyst again fill up, it may be necessary to open it, but the 
natural discharge from the submaxillary gland should be carefully 



1 82 ORAL PATHOLOGY AND PRACTICE. 

provided for. There are instances in which it will be found neces- 
sary to dissect out as much of the inciosing membrane as is 
possible. There is little danger from bleeding in any operation 
upon cysts, if carefully performed, and the only complications are 
those arising from the ordinary inflammations. 



CHAPTER XXXIX. 
TUMORS AND NEOPLASMS. 



It is not the purpose of this work to enter upon any extended 
investigation of diseases not commonly encountered by the dentist, 
or which properly belong to the practice of the general physician 
or that of any other specialist. But it would not be complete were 
not a sufficient knowledge of morbid growths imparted to enable 
the student intelligently to diagnose the condition, even were it 
essential for him to refer his patient to the general surgeon for any 
necessary operation. Hence, some general remarks will be at- 
tempted concerning the origin and pathology of the more common 
foreign growths. 

The term Tumor implies an abnormal enlargement of a part 
from any non-inflammatory cause, but usually from a morbid 
growth, which in its structure conforms to a greater or less extent 
to the tissue in which it grows, and which has no functional action. 
A simple inflammation is a tumor in one sense, but not ia that 
which is surgically the accepted one. The term Neoplasm is more 
applicable to the conditions under consideration, because it implies 
an abnormal growth, which may be either normally or abnor- 
mally located. 

All neoplasms, or tumors, consist of tissue that is normal to the 
body, and that forms an essential part of it when properly devel- 
oped. But when any tissue of the body grows in a location that is 
foreign to it, or when it develops in an abnormal manner or in 
excessive amount, it becomes a tumor or neoplasm. Every hyper- 
trophy is a tumor, because it is an excessive development, though 
of a normal tissue in a natural locality. If it is developed in an un- 
natural position, there is a greater departure. If fibrous tissue 
develops unconnected with other such tissue, or in a place in which 



TUMORS AND NEOPLASMS. 183 

fibrous tissue does not belong, it is a neoplasm. If osseous tissue 
develops in undue amount in connection with other bone, it may be 
but an hypertrophy or a hyperplasia. But if it is formed in an ab- 
normal manner, or in an unnatural location, it becomes a morbid 
tumor. A wart is the undue development or an hypertrophy of one 
or more of the papillae of the skin, and it is thus a form of benign 
tumor. A corn is the impaction of the epithelia in the tissue be- 
neath, but it is not a true foreign growth. When epithelia develop 
unduly in the midst of other tissues, they form a dangerous kind of 
tumor. 

Neoplasms may be of benign or of malignant growth. In the 
former case the tissue elements may form a mere harmless hyper- 
trophy, like hypercementosis, sometimes called exostosis of a tooth, 
while in the latter they are essentially foreign, and therefore irri- 
tants, and cause a degeneration and breaking down of tissue. All 
neoplasms, therefore, are composed of normal cells abnormally 
developed in number, as in hypertrophies; in position, as in 
warts, moles, etc.; or in both location and histological arrange- 
ment, as in the malignant tumors. 

They are named according to the tissue in which they occur, or 
of which they are composed. 

An Epithelioma is composed of unduly developed epithelia. 

A Fibroma is composed of unduly developed fibrous tissue. 

An Osteoma is composed of unduly developed osseous tissue. 

An Adenoma is composed of unduly developed glandular tissue. 

An Enchondroma is composed of unduly developed cartilage tissue. 

A Myoma is composed of unduly developed muscular tissue. 

A Glioma is composed of unduly developed nerve structure tissue. 

An Angeioma is composed of unduly developed blood tissues. 

A Myxoma } of unduly developed mucous and gelatinous tissue. 
Tumors are also named from other peculiarities, appearances 
and structural character, as — 

Sarcoma; having the appearance of flesh. 

Encephaloid; having the appearance of a head. 

Myeloid; having the appearance of marrow. 

Melanotic; having a pigmented or colored appearance. 

Scirrhus; having a hard appearance or consistence. 

Medullary; having a soft appearance or structure. 

Tumors are also Homologous or Heterologous, the former con- 



184 ORAL PATHOLOGY AND PRACTICE. 

sisting of tissue like, and the latter Tinlike, that in which it is im- 
bedded. Homologous tumors naturally are apt to be benignant, and 
heterologous tumors to be malignant in their nature. 

Malignant tumors are usually connected with some peculiar 
diathesis, and there is an hereditary tendency toward their forma- 
tion. They are embryonic in structure; that is, made up of not 
fully developed tissue, and hence quite unlike ordinary hyper- 
trophies. They are apt to consist of a network of connecting 
tissues, whose meshes are filled with abnormally developed cells. 

They may be diagnosed from their position, their history, 
growth, pain, general appearance, etc. As a rule, the faster the 
growth the more threatening the tumor. This is especially the 
case if there is pain attending it. Those which appear in middle 
age are more apt to be malignant than those whose growth is 
earlier. The most destructive ones are, after a certain stage, accom- 
panied with an extensive ulceration and sloughing of the tissues. 

A tumor will usually first appear as a hard nodosity within 
the tissues. It may increase in size very fast, or its growth may 
be slow. It may be accompanied with considerable pain, or it may 
be without functional disturbance. There are a great many benign 
tumors to each one of a malignant character. As a rule, if the 
growth is slow and without pain, if there is no special reason for 
its appearance, if it can be attributed to no particular pathological 
condition and no functional disturbance is connected with it, little 
attention need be paid to it. It is probably one of the frequent 
hyperplasias of an innocent character that may be found in almost 
every person. It is usually safe under all circumstances to allay 
the fears which such an appearance almost invariably excites, by 
the assurance that it is one of the numerous growths that can do 
no harm, and to endeavor to divert the mind from all thoughts of it. 
Nothing should ever be said that can excite apprehension. Even if 
the practitioner is in doubt concerning its true nature, he should 
not let the patient become aware of it. He should keep it under 
observation until it has sufficiently developed to enable him to judge 
intelligently, but always without communicating alarm. 

The treatment of the homologous tumors is wholly local. They 
have no constitutional origin, and do not menace life. The chief 
reason for interfering at all in many such cases will be found in the 
fact of their causing inconvenience or disfigurement. 



TUMORS AND NEOPLASMS. 1 85. 

The heterologous tumors represent a constitutional vice. They 
tend to infiltrate into and invade other tissues. Especially are they 
likely to affect the glandular system. Local treatment is entirely 
useless, and even if they are removed they are quite likely to re- 
appear. They never, like the homologous tumors, reach a definite 
limit of growth, but continue to increase and spread. Their treat- 
ment, aside from surgical interference, which is usually advisable 
except in the later stages, must be specific and sustaining. 



CHAPTER XL. 
TUMORS AND NEOPLASMS (Continued). 

The term Cancer is one that is not usually employed by pro- 
fessional men. It is derived from the Latin cancer, a crab, and 
the name is given from the supposed crab-like appearance of the 
veins in this affection. The laity usually understand by it any of 
the malignant growths which are technically called Sarcoma or 
Carcinoma or Epithelioma. Of these the sarcomata are composed 
of embryonic tissue from the mesoblastic layer, while the carci- 
nomata are of epiblastic origin. Each is variously subdivided 
according to its character or development, and each presents sepa- 
rate physical and pathological characteristics. 

Sarcomas have a distinct kind of fleshy appearance, and seem to 
be specially vascular. They grow along the lines of least resistance,, 
and are likely to penetrate into cavities and fissures of the tissues. 
They appear at any age, and are comparatively rapid in their 
growth, sometimes causing considerable pain. When they appear 
upon the surface they bleed very easily, and have in such cases 
sometimes been known as Fungous Hematodes. They are com- 
paratively frequent in the salivary glands, in the jaws and other 
tissues of the mouth, sometimes penetrating to the antrum. They 
are quite common in some of the lower animals, especially the 
horse. 

An Osteo-sarcoma is one in which the bone tissue is in- 
volved. It may be Central, arising in the interior and distending 
the bony walls ; Infiltrating, when the whole bony mass is perme- 



i86 



ORAL PATHOLOGY AND PRACTICE. 



ated and softened, or Periosteal, when it has its origin in the 
periosteum. (See Fig. 50.) 

Carcinoma is of epiblastic origin, and is connected with some 
form of gland tissue. It is rare in young persons, and it commonly 
involves the lymphatics at an early period of its development. It 
is usually rapid in its growth, and it may cause a very great degree 
of pain. It is very apt to attack the breast in women, but its seat 
may be in the sebaceous glands, the salivary glands, the prostate, 

Fig. 50. 




Osteo-Sarcoma of the Lower ]i 



(From a specimen in the Buffalo College Museum.) 



liver, kidney, testicles, stomach, intestines, especially the rectum, or 
wherever glandular tissue exists. Hence its location will be an 
important guide in its diagnosis. 

Epithelioma, as its name indicates, is a degeneration of an epithelial 
surface, usually of the skin, and consists of masses of epithelial cells 
surrounded and separated by bands of connective tissue. It belongs 
to the malignant growths, though it does not necessarily assume 
their form. It is most apt to attack those beyond middle life, and 
is much more common in men than in women. It sometimes 



TUMORS AND NEOPLASMS. 187 

arises upon the lip, from the long-continued irritation of a pipe. It 
is also not infrequently caused upon the tongue, or in the oral tis- 
sues, by the pressure of rough, sharp edges in carious teeth, which 
act as a continuous provocation. Its diagnosis is not usually diffi- 
cult. Its late and superficial appearance and the chronic ulcer 
with indurated edges forbid its being readily confounded with any- 
thing else, unless it might be some forms of syphilis. 

Lupus is one of the many forms which tuberculosis assumes. 
It is strictly a communicable disease, and is due to an infection by 
the tubercle bacillus. It usually commences early in life upon the 
face, in the form of small red or dark spots, which are much softer 
than the inclosing tissue. They ulcerate in time, and, spreading 
with the deposition of more tuberculous matter, there is a steady 
erosion into the surrounding territory. The infection of the system 
with the tubercle bacillus is always a grave matter, and is liable to 
cause many complications. It is a question to be taken into careful 
consideration when any surgical measures are contemplated, be- 
cause the appearance of miliary tubercle would interfere with the 
healing process. It is impossible within the limits of a work like 
this thoroughly to consider the many phases which tuberculosis 
may assume, and the student who desires further information is 
referred to works upon general surgery. 

Of the non-malignant tumors, those most commonly found in 
the mouth are the different forms of fibroma. These, as their name 
indicates, are composed of fibrous tissue. They are ordinarily 
dense in structure, and composed of bundles closely packed to- 
gether, which are permeated by bloodvessels. The Epulids belong 
to this class, as they are of fibrous origin. 

Lipomas, or fatty tumors, are the most frequent of any of the 
neoplasms. They are of the adipose tissue type, and it is needless 
to say are harmless in their character. They are usually inclosed 
in a capsule, from which, if no vital organ is involved in these folds, 
they may readily be enucleated. They are easy of recognition, 
except when deeply located, and when once extirpated are not apt 
to return. • 

The Osteomas are bony tumors, and are by some believed to be 
chondromas, or cartilaginous tumors, which have ossified. They 
may be either compact or cancellous in structure. They are most 
common about the cranium, and may be found in the frontal sinus, 



1 88 ORAL PATHOLOGY AND PRACTICE. 

the external auditory meatus, and about the mastoid process. The 
compact forms are sometimes very dense and hard, appearing like 
ivory, and they may defy the finest steel instruments. Some forms 
of odontoma are classed with osteomas. 

The student will be especially interested in the methods by 
which tumors of malignant growth may be distinguished from 
those which are benign. This may usually be done by the clinical 
symptoms, although there are instances in which the most careful 
observation will be at fault. Some of the foreign growths will pre- 
sent misleading characteristics, but the following points of differ- 
ence may usually be relied upon: 

Benign tumors are common to all ages, while those which are 
malignant do not appear in early life. 

Benign tumors are slow in formation, while the malignant are 
usually of rapid growth. 

Benign tumors do not spread and infiltrate into the surrounding 
tissues, while those which are malignant infiltrate in all cases. 

Benign tumors are often inclosed in a capsule and are circum- 
scribed, while malignant tumors are never thus limited. 

Benign tumors are rarely adherent, while malignant ones al- 
ways are. 

Benign tumors rarely ulcerate, while the malignant ones al- 
ways do when they come to the surface. 

In benign tumors the overlying tissue is not disturbed, while 
in the malignant it is more or less retracted. 

There is no lymphatic involvement in the benign tumors unless 
they are inflamed, while malignant tumors almost always involve 
the lymphatics. 

The treatment of the tumors is almost exclusively surgical. 
Those which are benign seldom return when they have been ex- 
tirpated, while the malignant ones usually do. If the latter have 
made considerable progress, and especially if the lymphatic glands 
have become enlarged and indurated, they are almost certain to 
reappear. Yet excision, even of the most destructive forms, will 
usually prolong life, if it does not permanently save it. There is 
but one safe method of removing them, and that is by the knife. 
The eroding plasters of the so-called "cancer doctors" are not only 
the most painful means of effecting removal, but are eminently 
dangerous, being very apt to hasten infiltration, and in some in- 



TUMORS AND NEOPLASMS. ISO, 

stances they may convert a tumor of a benign aspect into a malig- 
nant type. 

The dentist will be mainly interested in the epulitic growths 
that are common in the month. The nsnal form of epnlis is a vas- 
cular tnmor that appears upon the gums. Its origin may be from 
the superficial fibers, from the pericementum of a tooth, or it may 
penetrate into and appear to have its root in the alveolus. The 
term "Epulis" means "upon the gums." Hence it is applicable to 
any abnormal gingival growth, and the hypertrophies that, proceed- 
ing from the gums, sometimes fill the cavities in decayed teeth are 
true epulids, though of a simple character. Epulids may appear 
as erectile or as non-erectile tissue, and may have fibrous, myeloid, 
myxomatous or sarcomatous complications. 

The erectile epulids are vascular growths, whose size depends 
upon the vascular condition, and they vary with this. When dis- 
tended they appear tinged and dark. When not distended they are 
flaccid, pale, and contracted. 

The epulitic tumors that spring from the periosteum perhaps 
invade the substance of the bone. They may be diagnosed by 
careful movements and by the exploring needle, which may pos- 
sibly detect an opening into the bone. 

If the origin is from the pericementum of a tooth, a peduncular 
connection may usually be traced, either through the alveolar walls 
or by the side of the tooth, in the direction of the pericemental 
membrane. 

For the removal of the superficial and erectile tumors, little 
more is needed than a ligature that shall cut off all circulation, with 
final cauterization of the place. An epulis that has its origin in the 
pericementum of a tooth will be cured by extraction. But for 
those which penetrate the bone, it will be necessary to remove as 
much of the alveolus, or even the 'body of the maxilla, as is affected, 
remembering that the extremity of the invasion must be reached. 
The wound should be dressed with iodized lint. If there is much 
inflammation the following may be applied : 

3 — Plumbi acetatis, 3ij ; 

Tinct. opii, Sij ; 

Aquae, 3xvj. 

Sig. — Pack the wound with lint wet with the solution. 



I90 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XLL 

OSTEITIS. 

Before entering- upon the consideration of diseases of the 
bone it is necessary thoroughly to comprehend the pathological 
changes involved in the initial steps of the degeneration. Bone, 
which forms the framework of the body, is made up of an inorganic, 
or mineral portion, and an organic, or living part. The latter is con- 
tained within the meshes of the former, and communicates through 
the whole' structure of the bone. This is accomplished by means 
of the peculiar formation of the inorganic part. It is through the 
organic or living portion that nutriment of the whole osseous 
tissue is carried on. The changes that occur in the inorganic 
portion, the waste and repair, are not, of course, as great as those 
of vascular tissue, yet they must be provided for in the economy of 
nature. 

The nourishment of the bone, like that of all other tissues, must 
primarily be derived from the blood, and it is carried on through the 
periosteum or investing membrane, the medullary marrow or central 
cavity in long bones, and the Haversian or penetrating canals which 
carry the blood to all portions of the thick bones. Around the 
Haversian canals, and along all the sources of nutriment, are 
arranged a concentric series of cells containing the essential living 
matter of the bone. (See Fig. 51.) These cells are the lacunae, 
and each of the zones of these so concentrically arranged cells is 
called a lamella. Connecting the several lacunae, and communicat- 
ing with the nutrient source — the periosteum, the medulla, or the 
Haversian canals — are the canaliculi, the minute canals which carry 
the pabulum extracted from the blood to the lacunae, the immediate 
source of nutriment. 

The living contents of the lacunae and the communicating 
canaliculi are of a protoplasmic or embryonal character, and contain 
the elements of the osseous tissue. If the nutrition of its structure 
is cut off, the bone dies as inevitably as does any other tissue under 
like circumstances. If a ligature is placed about the ringer that 
is sufficient to prevent all circulation, and thus to stop all nutriment, 
the soft tissue will die and become gangrenous. If the ligation is 



OSTEITIS. 



I 9 I 



so complete as to deprive the bone of its nutrient currents, that will 
also die from the same reason, and become necrosed. 

If the stoppage of nutrition in the finger is through a progres- 
sion of the inflammatory process, by hyperemia, congestion, and 
final stasis of the blood current in the part, the result is precisely 
the same as if it were through a ligature, or separation of all arterial 
sources of supply. It matters not by what the nutrition is com- 
pletely interrupted, whether by starvation — stoppage of food supply 
either to a part or the whole of the body by cutting off that supply 

Fig. 51. 




Lamellae of Bone, showing also the Lacunae and Canaliculi. (From Gray.) 



through interruption of the channel of conveyance — or by such 
pathological changes as completely to prohibit assimilation of food 
products, death of a part or the whole of whatever is thus deprived 
of its food supply must be the inevitable result. In the soft tissues 
this may be called suppuration, ulceration, sloughing, or gangrene, 
and in the hard portions caries, exfoliation, or necrosis, but it is 
essentially all the same process. Each is but a different manifesta- 
tion of the universal law of death and decay whenever nutrition and 
progress cease. The instant that progression stops, retrogression 
commences. 

The contents of the lacunae and canaliculi of bone, the proto- 
plasmic embryonic elements, although they are not directly vas- 



192 ORAL PATHOLOGY AND PRACTICE. 

cular, may be the subjects of inflammatory action. This process, 
differing from ordinary inflammation in some particulars because 
of the varying physical character of the affected substance itself, 
as well as of its environments, will arise from the same causes as 
do inflammations of other tissues, and may be studied from the 
same standpoint. 

The initial point will undoubtedly be in the tissue or organ 
that is the immediate source of food supply, — the periosteum, the 
investing or lining membrane of the bone. Disorders of this tissue 
must affect the living portion of the bone. Inflammation of the 
periosteum, if the degenerative process continues, ends in stasis of 
the blood currents, thus cutting off nutrition, with the consequent 
deterioration of the living contents of the lacunae and canaliculi. 

This inflammation, or affection of the living portion of the bone, is 
that which we call osteitis, and it is usually the initial point of necrosed 
conditions. If the osteitis is relieved through the" removal of the 
source of irritation and the re-establishment of nutrient currents, 
that is essentially the resolution spoken of in dealing with Inflam- 
mations. If it proceeds to the breaking down of tissue it will be 
caries or necrosis, the analogues respectively of suppuration and 
gangrene. 

Like all other inflammatory conditions, osteitis is the result of 
some irritant. This may be a traumatic lesion, the presence of 
pus or of a foreign body, or the interference with nutrition caused 
by some external impression manifested through the nervous sys- 
tem. Anything that would induce the inflammatory process in the 
soft tissues may in a less degree be provocative of osteitis in the 
hard. Probably there was never an acute pericementitis that did 
not induce a corresponding osteitis in the bony tissues in the imme- 
diate proximity. We know that an alveolar abscess causes a 
breaking down of the bone about the infected spot, and the forma- 
tion of a cavity of greater or less extent. We are also but too well 
aware that pus from an abscess sometimes infiltrates the bone, and 
will burrow to a considerable distance, forming secondary pockets 
and foci of infection, which sometimes make thorough sterilization 
very difficult. We know, too, that it takes considerable time to 
effect the complete healing of the pockets and cavities in the bone 
thus formed, and that until the embryonic or temporary tissue that 
is the result of the first reparative process shall have time to con- 



OSTEITIS. 193 

solidate and become permanent through further progressive 
changes, there is always danger that the metamorphosis will take 
upon itself a retrogressive state and the whole again break down. 
All these conditions go to demonstrate the fact that osteitis, to a 
greater or less degree, is always present in pericemental complica- 
tions, and that in the treatment of such conditions its existence 
should be taken into account and care taken that it be kept in 

check. 

Symptomatology and Treatment. 

The diagnosis of osteitis as a separate infection is not readily 
made, and principally depends upon other known degenerative 
processes. The existence of an abscess in the immediate neighbor- 
hood of any osseous tissue must inevitably induce it. The mere 
presence of pus and of the micro-organisms of suppuration are 
sufficiently irritating to provoke an inflammation of periosteum, 
and that necessarily implies more or less of osteitis. But aside 
from such recognizable complications the condition does not pre- 
sent sufficient of pathognomonic symptoms to enable the observer 
always to detect it in its earlier stages. It may often be inferred, 
and in some instances perhaps determined, by exclusion of all other 
functional disturbances, but the pathologist must mainly depend 
upon associated disorders for his complete diagnosis. 

The periosteal inflammation that is the cause of, or that 
accompanies it, will manifest itself by a red line, or red blotches 
upon the superincumbent tissues, provided they are not too thick, 
and this will be intensified if there is very much of osteitis present 
But this cannot be depended upon as a certain diagnostic symptom, 
though it may be useful as an adjunct. 

The treatment of osteitis in its early stages should be abortive, 
and it will not materially differ from that laid down for the relief 
of inflammation in other tissues in the chapter (X.) devoted to 
that subject. Its presence once determined, every effort should be 
made to discover the source of irritation and to remove it. About 
the jaws this will most frequently be a diseased tooth, and when 
that is restored to a healthy state, unless the disorder shall have 
existed for some time or the lesions be unusually violent, the 
inflammation in the lacunse of the bone will subside with the rest. 
If, however, this is not the case, and the retrogression or degenera- 
tive action persists, it will result in either caries or necrosis of the 
bone, and these will be considered under their appropriate heads. 

14 



194 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XLIL 

CARIES OF ALVEOLAR BONE. 

In dental practice this disease may be compared to suppuration 
or ulceration in soft tissues. It is the devitalization of bone, cell 
by cell, and its breaking down by a comparatively slow progression, 
rather than death in mass. It has its origin in perverted or inter- 
rupted nutrition, but the phenomena exhibited vary somewhat from 
those of necrosis. It most frequently arises from local irritations, 
but it may be general and constitutional in its origin, as in the case 
of scrofulous subjects or those affected by the syphilitic virus. A 
frequent source of maxillary caries will be found in the diseased 
roots of teeth, which act as sources of irritation. Not infrequently, 




Loss of Septa through Alveolar Caries. 
a, Depressions in the bone, with denudation of the cervix of the tooth. 

too, it is the result of excessive violence in dental operations. 
Long-continued wedging will be likely to induce a local osteitis so 
severe as to interfere with the nutrition of the thin septa of bone 
between the teeth, denude them of periosteum, and result in a 
wasting caries which will destroy that portion of the alveolar 
process by slow disintegration. (See Fig. 52.) 

It will be comprehended that this form of caries materially 
differs from that which is by surgeons usually denominated caries 
of the bone, both in its etiology and symptomatology. While it 
may be aggravated, or even induced, by cachectic conditions, it is 
not characterized by the substituted granulation tissue. It more 
resembles in its progression dental caries, but is quite distinct from 
the latter in many of its characteristics. This form of caries of the 



CARIES OF ALVEOLAR BONE. 195 

bone may be readily diagnosed, through careful examinations, by 
any one who is skilled in such matters or who has cultivated habits 
of close observation. Yet the earlier periods in these perversions 
are recognized by but few dentists, because their perceptions have 
not been sharpened by continual practice. Either they are not 
sufficiently instructed to know what to look for, or they do not 
extend their observations beyond the teeth themselves, and neglect 
everything save that which obviously demands mere mechanical or 
operative interference. Any localized congestion or inflammatory 
turgescence and swelling demands the attention of the practitioner. 
It may be indicative of a slight disturbance, or it may be the initial 
point of a serious lesion. The oral physician should be competent 
to determine which it is, and faithful enough to keep it under 
observation until it shall develop its true character; and the condi- 
tion should be recognized early enough to enable the practitioner 
to obviate the spontaneous formation of sinuses. 

True caries of bone will produce a marked change in the over- 
lying soft tissues. There will in the incipiency be great determina- 
tion of blood to the parts, with congestion and tumidity. This will 
gradually assume a deeper color, until it approaches a purple hue 
and sloughing commences. 

In simple denudation caries of the maxillary process there will 
be very little of this, nor will there be any very considerable forma- 
tion of pus. But there will be limited sloughing of the superim- 
posed tissues, with denudation of the bone, more or less complete, 
beneath. An opening through the soft tissues will be found, and 
this may be discharging a small amount of pus, though without 
acute complications. If now a probe — the best one for such cases 
is a hatchet-shaped excavator — or an explorer of some kind be car- 
ried through this opening, the bone will be found quite denuded and 
exposed. The point of the excavator will readily enter it, and 
small spicula from the roughened surface may be readily chipped 
off. There will be none of the smooth, solid, resisting sensation 
that a healthy bone presents. To the educated sense of touch it 
presents characteristics that cannot well be mistaken. If there is 
caries of the septum of the bone between the teeth, the result of 
traumatic violence, perhaps in wedging or filling, there will be a 
peculiarly rough, gritty feeling, showing that portions of it have 
been thrown off, with destruction of the periosteum. There may be 



I96 ORAL PATHOLOGY AND PRACTICE. 

a distinct putrefactive odor from the diseased territory, showing 
that food is undergoing decomposition there, even if there is no 
appreciable formation of pus. These conditions and appear- 
ances distinguish alveolar caries from the resorptions of the 
alveoli which normally occur after the extraction of the teeth and 
the destruction of the pericementum, upon the integrity of which 
membrane the tooth sockets are dependent. 

The treatment of this form of caries of the bone will be almost 
entirely local. If the degeneration is extensive, it may possibly 
indicate a general debility that will demand the use of tonics, but 
this will be very unusual, to say the least. The dead and carious 
bone should be burred away with the dental engine, and, if neces- 
sary, the diseased surface carefully curetted or scraped. This 
process must be carried to the extreme limits of the affected bone, 
which, unless there is a carious sinus, will not be very deep. 

This done, and all debris carefully washed away, the surface of 
the diseased bone may be saturated with aromatic sulphuric acid, 
which may be allowed to act for a few minutes, when the cavity 
should be thoroughly washed with water. That an acid, especially 
sulphuric, will exercise a selective action, dissolving only dead tis- 
sue, seems to be proved by the experiments of the late Prof. J. E. 
Garretson, who caused to be submitted to the action of a twenty- 
five per cent, solution of sulphuric acid, for three days, fragments of 
dead, of diseased, and of healthy bone, with the result that in dead 
bone a considerable proportion of the lime salts was dissolved, in 
the diseased bone a less amount, while in the healthy bone no such 
action took place. Great care must subsequently be exercised to 
keep the territory clean and aseptic, disinfectants or antiseptics 
being used if necessary. 

If the tissues seem indolent, they may be stimulated to action 
by the use of a weak solution of the chloride or iodide of zinc. 
Opportunity must be given for the formation of a new periosteum, 
and when the reparative process is once under' way the forming 
tissue must be left undisturbed, except for occasional gentle irriga- 
tions with an antiseptic or stimulative solution when that is abso- 
lutely necessary. Many practitioners defeat their own efforts by 
uncalled for and meddlesome interference — by over-treatment when 
all is progressing satisfactorily. 

The preceding remarks apply more directly to caries of the 



CARIES OF ALVEOLAR BONE. 197 

alveolar process of the jaws. In caries of other bones there is 
almost always some cachectic condition, such as tuberculosis or 
syphilis, which induces the carious degenerations. (See Fig. 53.) 
If there is infection by septic organisms suppuration of course 
ensues, and the disease may assume a more destructively active 
necrotic type. In dry caries of the alveolar process, which is the 
form most frequently met with by the oral practitioner, there is 
nothing of this kind, nor is there necessarily a constitutional dys- 
crasia, the local irritation being sufficient to induce the gradual 
wasting of the cancellous bony tissue, through the gradually pro- 
gressive cutting off of nutrition. 

Fig. 53. 




Caries of Ulna and Radius. 
There are no such cavities found in the bone as in Fig. 54. 

In oral practice, then, a distinction may readily be made be- 
tween the carious disintegrations of the alveolar process of the 
jaws that may not be accompanied by any specially inflamed con- 
ditions and in which there are few if any traces of ulceration, 
and the porous, abscessed state of true caries, which is surrounded 
by foreign, unhealthy granulations of the soft tissues. The one is 
merely a gradual disintegration of the alveoli, brought about by the 
deprivation of the nutrient supply, with denudation of the process 
by sloughing of the periosteum. The other is the breaking down 
of osseous tissue with the formation of fetid pus, w T hich tends to 
burrow into the tissue. The first is due to simple lack of nutrition, 
usually the result of some injury, while the other is a cachectic 
state arising from some constitutional disturbance, the tuberculous 
deposit being its most frequent accompaniment. 

The only treatment demanded by the progressive crumbling 
of the alveolar process will be to remove any irritating cause, bur 
out the bone that is denuded of its periosteal covering and that is 



I98 ORAL PATHOLOGY AND PRACTICE. 

disintegrating", retain the gum tissue in place over it — by stitches 
if necessary — and then, by the use of stimulating astringents, to 
induce a new membranous growth. 

If there is an ulcerative condition, due to a dyscrasia, constitu- 
tional treatment will be demanded, and this will consist in the pre- 
scribing of nutritious diet, cod-liver oil, hypophosphites, syrup 
of iodide of iron, etc., with the local treatment previously recom- 
mended, and specific remedies when indicated. 



CHAPTER XLII'L 
NECROSIS. 



Necrosis of the hard tissue is the analogue of gangrene in the 
soft. Its progress is not so rapid, because of the difference 
in the physical characteristics of the tissues themselves. But its 
origin is in an identical disturbance of nutrition, its course presents 
the same pathological changes, the termination is usually similar, 
and the treatment involves the consideration of cognate principles. 
Inflammation forms the initial point in its morbidity, and it is from 
that standpoint that the degenerate modifications should be 
studied. 

Necrosis differs from caries of the bone rather in degree than in 
essence. As gangrene is the death of soft tissues in mass, so 
necrosis is the devitalization of a territory having an osteogenetic 
origin. Like caries of bone, its cause may be either traumatic or 
specific, local or constitutional. It may attack any of the bones, 
but the maxillae are especially subject to it; necrosis of the lower 
jaw is four times as common as in the upper. In simple caries of 
the alveoli this proportion is nearly reversed. When not the result 
of an injury, its origin is in an inflammation of the investing or 
lining membrane, which spreads to the lacunae of the bone, thus 
producing osteitis, which eventually reaches the point of entire 
inhibition of nutrient currents, with subsequent death of a territory 
more or less extensive. 

Necrosis is usually an indication of a weak, anemic, or debili- 
tated condition. When all the functions of life are active and 
general nutrition is good, vitality in a part will be maintained 



NECROSIS. 199 

despite unfavoring conditions. But when there are defects in the 
assimilative process retrogression is easy, and there is a predis- 
position to wasting diseases. The most fruitful source of necrosis 
of the maxillae will be found in the presence of decayed, diseased, 
irritating roots of teeth. These initiate inflammations, and exacer- 
bate them when once started, prevent nutrition, and hence provoke 
devitalization. When the suppuration of alveolar abscess takes 
place the pus may burrow beneath the periosteum of the bone, and, 
separating it, cut off nutrient currents from the territory beneath. 
This will be especially probable in the lower jaw, for drainage of its 
pus pockets is usually imperfect, while gravity constantly tends to 
bring about infiltration ; and this will in part account for the greater 
proportion of cases of necrosis in that bone. 

A fruitful cause for necrosis of the jaws will be found in im- 
pacted teeth, arising from the lack of room for their proper develop- 
ment. This is especially true of the third molars, the body of the 
jaw between the symphysis and the ascending ramus often being 
too short to afford room for all the teeth. When the time comes 
for the development and eruption of the wisdom tooth all the 
space is occupied; it is imbedded in the tissues without power to 
advance, and becomes a source of violent irritation. An inflamma- 
tion' is excited which assumes a peculiarly vicious character, "and, 
the irritant still remaining, there is breaking down of tissue, infec- 
tion, and suppuration. In the general degenerative state this 
spreads to the bone, with consequent acute osteitis and necrosis. 
This condition, to which the upper jaw is not as liable, yet further 
accounts for the disparity in the relative number of cases in the 
two jaws. 

Necrosis may also be the result of injuries done by the dentist. 
Fractures of the alveolus in extraction are very common, but such 
is the recuperative power of these very vascular bones that nature 
usually buries the faults of the incompetent or reckless operator 
beneath new formations. If, however, the patient is suffering from 
any form of atony, the reparative process may not be sufficiently 
active to restore the normal condition, and retrogression may take 
the place of progression. In such patients the mere careless punc- 
ture of the alveolus to some depth by a sharp-pointed excavator, or 
plugger, or engine bur that has been infected by some septic 
product, may produce inoculation that will result in serious necrotic 



20O ORAL PATHOLOGY AND PRACTICE. 

complications. Arsenous acid, when used in too great quantity for 
the devitalization of a tooth pulp, or if not securely sealed in the 
cavity of decay, may penetrate to the alveolus and produce a 
necrotic condition that will spread to other tissues. 

The pericemental inflammations consequent upon the death and 
infection of the dental pulp are a fruitful source of necrosis of the 
alveoli and maxillae. As has been elsewhere asserted, these always 
induce an osteitis more or less severe, and when the irritation is 
continuous, as in the case of atonic patients, it may very readily 
result in death of the adjacent bony tissue. The premature filling 
of the roots of septic teeth by the dentist has been responsible for 
many cases of necrosis. The introduction of the filling before the 

Fig. 54- 




Necrosis of Tibia, showing Cavities in the Bone. 

septic state shall have been completely made aseptic, and before the 
healing process has been fairly initiated, tends to keep up an irrita- 
tion which is fatal to healthy functional activity. 

Certain zymotic and exanthematous diseases sometimes have 
necrosed conditions among their sequelae. This is especially true of 
scarlet fever. Mercury, when given in large doses, may cause it. 
Tertiary syphilis is quite likely to attack the palate and nasal bones. 
People who, having dead teeth, work in match factories, are espe- 
cially liable to a form of affection called phosphor-necrosis, caused 
by the fumes of the phosphorus used, which is supposed to pene- 
trate through the root canal, and thus to come in contact with the 
pericementum which gives nutriment to the alveolar sockets. So 
universally is this special condition recognized, that in France every 
factory that uses phosphorus in the manufacture of matches must 
employ a dentist, whose duty it is periodically to examine all the 
inmates and forbid the employment of any that have dead teeth 
with unfilled roots. 



NECROSIS. 201 

The diagnostic signs of necrosis are usually distinct and well 
marked. With the death of the bone, the overlying tissues with 
which it is invested become peculiarly turgid and inflamed. They 
finally assume a characteristic purple tint, and look exceedingly 
angry. This is increased as the tissue commences to break down 
beneath the surface and suppuration ensues. There is little of the 
characteristic "pointing" of alveolar abscess, but the pus finds its 
way to the surface at a number of places, and the discharge is 
usually profuse and fetid. If now an explorer is passed into one of 
the sinuses until it reaches the bottom, the characteristic sensation 
imparted by dead bone will be plainly felt; or if the disease has been 
peculiarly active in its character deep cavities may be detected in 
the bone, with crumbling, disintegrating edges. (See Fig. 54.) 
Minute chips of the degenerated bone may be easily separated 
with any appropriate instrument. There will be the usual septic 
fever, and this may be decidedly pronounced. There will be a 
general malaise and loss of strength and vitality. 

The constant tendency on the part of nature is to get rid of the 
dead and irritating tissue. The very suppuration that accompanies 
all necrosed conditions is a part of this process. It is indicative of 
a disposition to slough away the diseased portion. Sometimes this 
is successful. There is a clear line of demarkation drawn between 
the dead and the living tissue, and the granular lymph acts as a 
kind of wedge to separate them. If this is accomplished, the dead 
part that is thrown off is called the Sequestrum. At the same time 
there will perhaps be a successful effort on the part of nature to 
reproduce the bone, and this may be outside of and envelop the 
sequestrum. Such new enveloping bone is called the Involucrum, 
and it may entirely prevent the exfoliation of the sequestrum. (See 

Fig- 55-) 

When there is extensive alveolar necrosis of a peculiarly active 

type it is not always judicious to extract teeth, even though they 

are plainly involved. There is a difference of opinion upon this 

point among pathologists, but it must be evident to all that if the 

disease is the result of an acute osteitis, and the attachment of any 

part of a tooth is in live bone, its extraction will produce a wound 

that will be certain of infection; the inflammation will spread and a 

new focus will have been produced, which might have been avoided 

had the tooth been left to the slower process of exfoliation. On 



202 



ORAL PATHOLOGY AND PRACTICE. 



the other hand, if the tooth is a distinct irritant that is aggravating 
the situation it should be removed, provided it may safely be done. 
It will therefore be seen that it sometimes requires the nicest dis- 
crimination to determine this point. 

If there is a tendency toward the formation of a sequestrum, 
the dentist should not be precipitate in attempting its removal. 
He naturally desires to hasten this process, but good judgment 
must be employed, and it is usually safest to await the exfoliation 
which will follow in due time. If it is violently torn away before 

Fig. 55- 








Necrosis of Humerus, showing Sequestrum and Involucrum, the One Found 
Within the Other. 

the separation of the dead from the living tissue is completed 
by nature an open wound is produced, as in the case of extraction 
of a tooth, and at this point, minute though it may be, inflammation 
may begin anew and the diseased state thus be aggravated. But 
when a fissure of separation can be felt, a pledget of antiseptic cot- 
ton or gauze may be crowded in, and thus a little pressure made to 
assist the process of exfoliation. 



CHAPTER XLIV. 



TREATMENT OF NECROSIS. 

The treatment of necrosed conditions may be divided into three 
parts, — local, operative, and general. The first will consist of the 
use of disinfectants and depurators. There will be little occasion 
for antiseptics, because the flow of pus cannot be prevented as long 
as there is dead bone. But the whole diseased territory should be 
kept as carefully drained as possible, and it should be frequently 
and effectually cleansed with some good disinfectant. For this 



TREATMENT OF NECROSIS. 203 

purpose electrozone, or meditrina, will be found especially useful, or 
peroxide of hydrogen, or a three per cent, solution of pyrozone 
may be injected with a syringe or applied with an atomizer. If 
the discharge of pus is into the mouth, that cavity should be fre- 
quently washed with an antiseptic gargle, and as much care as pos- 
sible should be exercised to avoid swallowing the septic products. 
A drainage tube, or strip of iodoform gauze to serve as such, may 
be introduced into the sinus if its location is such as to demand it, 
and this may be held in place, if practicable, with strips of adhesive 
plaster. Of course, neither of these will be appropriate if the dis- 
charge is within the oral cavity. 

Sulphuric acid may, in some instances, be profitably employed 
to dissolve out the dead bone. It may be used in such strength as 
the nature of the case demands, from a dilute aromatic solution to 
the chemically pure. Of course the latter will only be employed 
with caution. There is no danger to the soft tissues involved, 
unless possibly from the chemically pure, and even that involves 
no serious effect if it is properly used and washed away in time. 
Local stimulants may be employed to overcome the indolence if 
necessary. 

The operative measures to be employed will consist of those 
necessary to secure perfect drainage, and operations for the re- 
moval of the dead bone. Sometimes in the lower jaw a deep pocket 
will be formed in the body of that bone, through the enlargement 
by necrosis of the socket of a tooth which was the original cause of 
irritation. Drainage of this may be impossible, through the in- 
ability of the tissues to expel the pus over the borders. 

In one such case the author, against his own better judgment 
but at the solicitation of both the patient and the dentist who had 
referred her to him, attempted in vain the acid treatment after thor- 
ough burring out of the necrosed cavity. The pocket could not be 
kept clean, and reinfection from the retained pus was certain, 
until an anesthetic was given and an opening made from outside 
the face and beneath the jaw into the cavity. A strip of iodoform 
gauze was then passed through into the mouth, drawn back and 
forth repeatedly, and the end finally left projecting from the 
external wound to assist in drainage. The result was a speedy and 
complete cure, without the use of any other agents. In some cases 
of necrosis of the upper jaw, operative measures may be necessary 



204 ORAL PATHOLOGY AND PRACTICE. 

to open completely and straighten out the sinus of discharge. This 
may be readily done by a proper bur in the dental engine. 

The operation for the complete removal of dead bone in the 
maxillae may be of a formidable character, and its consideration 
properly belongs to the domain of oral surgery. It must be thor- 
oughly done, if done at all. Half-way operative measures are of 
little account. The patient, having been properly fortified with 
nourishing food for a time, is anesthetized and placed in such a 
position as will afford complete command of the situation. The 
superincumbent tissues are laid back by the proper incisions, the 
blood checked by ligatures or the use of hemostatic forceps, and 
the territory carefully sponged and examined. When the extent 
of the lesion is fully determined, the proper steps are taken for the 
removal of the dead and diseased bone by the use of the dental 
engine, bone chisels, scrapers, and saws. When this is completed, 
all exposed edges of bone must be made smooth, every particle of 
debris removed, and the wound antiseptically washed and properly 
closed, with sutures if necessary, a drainage tube inserted, the 
exterior dusted with iodoform powder, and the whole enveloped in 
the proper bandages and dressings. If the wound is wholly within 
the oral cavity, of course the iodoform dusting and the bandaging 
will not be called for. The desirability of working within the 
mouth when practicable cannot be too strongly urged, especially in 
the case of young women, that disfigurement may not be the result ; 
but the success of an operation should not be jeopardized in the 
effort to avoid minor disfigurement. A visible scar is better than 
death, or even the entire loss of a bone. 

General or systemic treatment is called for in almost every case 
of extensive necrosis. The disease is of such a wasting nature that, 
at the very least, tonics and a sustaining diet will be called for. 
The patient should be made to live out of doors as much as pos- 
sible, and every hygienic precaution be taken. If the lesion is the 
result of some cachectic condition, like syphilis or mercurialization, 
the general treatment proper to such condition must be instituted. 
For the former a strict course of specific treatment will be de- 
manded. The subject is presented in another chapter, and hence 
it is not necessary to pursue it farther in this connection. 

The tonics that are used in wasting diseases are of two kinds, — 
vegetable and mineral. The former consist mainly of the bitter" 



HYPERSENSITIVE DENTINE. 205 

barks of certain trees, while the latter are inorganic substances that 
exercise a peculiarly stimulant or alterant action that tends to pre- 
vent waste or assist nutrition. Of the vegetable tonics, Peruvian 
bark or cinchona, quassia, gentian, and wild cherry, with their alka- 
loids, are those most commonly employed; while the inorganic or 
mineral agents most used are preparations of iron, of copper, and 
of zinc, with such other remedies as subnitrate of bismuth and sul- 
phuric, nitric, hydrochloric, and oxalic acids. 



CHAPTER XLV. 
HYPERSENSITIVE DENTINE. 



Were it possible to rob operative dentistry of the horrors too 
often its determined attendant in the pain and anguish that excava- 
tion of carious teeth causes, public health would be greatly con- 
served and human life would be correspondingly lengthened, because 
of the greater care that would be bestowed upon those organs. 
Would the public generally learn to look upon the dentist in 
his true light, — that of one whose mission it is to avert pain and 
suffering, — he would be regarded with much greater favor and 
would enjoy higher consideration. But the nature of his work is 
such that, like the general surgeon, in his efforts to forestall future 
anguish he too often brings present distress, and too many who 
should be his patients choose to postpone the evil day and hazard 
all the future rather than risk a moment of the present. 

Recognizing all this, dentists from the earliest period in the 
history of their art have been constantly striving to devise some- 
thing that will give exemption from pain in dental operations. 
Most of their efforts have been entirely empirical, and often experi- 
ments and labors have been conducted in a haphazard way that 
betokens anything but professional erudition or scientific knowl- 
edge. Those who have claimed to accomplish anything in the way 
of a solution of the problem, have not usually been those who were 
best equipped by education and professional attainments for the 
task. The practitioner who advertises "painless dentistry" has 
passed into a byword, and the term is a synonym for an impostor 
and a charlatan. Almost invariably those who have brawlingly 



206 ORAL PATHOLOGY AND PRACTICE. 

boasted that they have discovered a universal panacea for all dental 
pain have been illiterate, undisciplined, unknown pretenders, whose 
sole object was to secure a dirty dollar by unprofessional methods, 
and to make profit out of that which should be public philanthropy; 
men who would, if possible, garner the sun's beams and peddle 
them out for individual gain; who would put holy things to an 
unholy use, and make of human beneficence a public prostitute. 
Of this character have been most of the widely advertised prepara- 
tions for obtunding the dental tissues, — quack remedies, prepared 
by dental quacks for quackish purposes. The student and practi- 
tioner should avoid them if he is an honest man, for he has no 
moral right to recommend to a patient, who pays him for special 
knowledge, any drug of whose exact nature and therapeutic value 
both are alike ignorant. 

In its normal condition dentine should be without sensation. 
There are no organized nerves to convey impressions, even were the 
tooth-bone subject to them. Yet the protoplasmic, albuminoid con- 
tents of the dental tubuli may, under special irritation, become 
the subjects of inflammatory conditions, in which they not only re- 
ceive, but readily transmit to the dental pulp, external impulses 
of a painful nature. (See Fig. 56.) It is true that the pulp of the 
tooth is supplied with nerves ; yet they are without some of the 
characteristics of ordinary nerves, and, protected from all irritating 
shocks as it is in its normal state, even the pulp is not of itself 
responsive. Only when some of its protection is withdrawn, or 
when from some reflex source the pulp is subjected to special 
irritation, does it become impressible to outward agencies and con- 
vey disagreeable sensations. 

We know f hat it is a law that animals, and organs and tissues, 
adapt themselves to their environments and change their structure 
with varying conditions. Thus the fishes of rayless caverns lose 
their sight, and certain inhabitants of the greatest ocean depths are 
without the usual sensory functions. Both, by gradual transmis- 
sion to other surroundings, would develop special senses, as have 
other organisms. Continual subjection to external irritation may 
either weaken or develop the corresponding sentient perceptive- 
ness, through which alone can defense and security be obtained. 

That both dentine and dentinal pulp are without ordinary- 
sensation when in a perfectly healthy and normal condition, is 



HYPERSENSITIVE DENTINE. 2.0J 

proved by the fact that when a healthy tooth is fractured and the 
pulp thereby completely exposed, it is irresponsive to external irri- 
tants for a short time. Healthy pulps are painlessly "knocked out" 
by a certain class of practitioners, provided the teeth are sound and 
the work is done quickly enough. But if there is the least inflam- 
mation in either pulp or dentinal fibrils the operation is anything 
but painless. There is not a practitioner of extended experience 
who has not at some time cut into the dental pulp entirely without 
the knowledge of his patient, provided he was excavating in dentine 
that was completely or even comparatively irresponsive. 

Fig. 56. 








it;!*' 



Formative Dentine, showing the Protoplasmic Fibrill^e. 
a, Odontoblast cells of the pulp, with Tomes fibers or dentinal fibrillae ; b. Forming dentine. 
c, Formed dentine cut diagonally across the tubules. (Andrews.) 

The source of sensitive dentine, or of impressionable pulps, lies 
in their continued subjection to irritation, by which responsiveness 
is developed. The freshly exposed pulp, or dentine, of a perfectly 
healthy tooth, is without sensation. But a few moments of subjec- 
tion to external influences, the air and other irritants, are sufficient 
to produce a marked change in the tissues, and they become 
exquisitely responsive. A kind of inflammatory degeneration 
takes place, and normal function is so altered that disagreeable 
currents are conveyed. This is in perfect harmony with the other 



208 ORAL PATHOLOGY AND PRACTICE. 

known processes of Nature, for in the presence of danger she 
always develops means of defense by giving warning through the 
awakened senses. 

If, then, in the normal state the tooth tissues are without 
sensation, it follows that if a pathological condition is succeeded 
by one of perfect health, the immunity to pain should be re-estab- 
lished. This is undoubtedly the fact, for teeth that have been 
attacked by caries, and which under its influence have become 
painfully sensitive, have, when the broken continuity has been 
restored by a filling, lost that responsiveness and again become 
insusceptible to external impression. It is true that this is not 
always the case, because the very material that has been used to 
mend the broken place may of itself become an irritant and per- 
petuate the abnormal state. Were it possible to fill an ordinary 
tooth with something that would be perfectly congenial to the 
tissues, there is little doubt that all filled teeth would be comfort- 
able, and herein may be found a reason why certain materials, 
aside from their lasting qualities, make the best fillings. 

The test for the perfect success of an operation is the condition 
of the tissues which ensues, — because recurrent decay is not the 
first symptom of the failure of an operation. It may be found in the 
responsiveness of the dentine to external irritants ; in its sensitive- 
ness to outward impressions. Not that it is always possible com- 
pletely to restore to healthy functional activity a tooth that has 
been subjected to operative filling. Usually only toleration with 
mild protest can be obtained for the foreign matter that is used 
for protective purposes, especially if it is of a metallic nature. 
When there is permanent denudation of any part, as in recession 
of the gums, normal conditions cannot even be approximated. 

One of the causes of the irritation in which is found the source 
of sensitive dentine is caries. This is of itself a pathological con- 
dition of dentine, and its progress necessarily entails other degen- 
erative conditions. The disintegration of portions of the tooth- 
bone, with the consequent destruction of parts of the dental fibrillar 
must affect that with which it is in connection ; and so there will be 
an irritable, disordered condition of the whole of the dentine, with 
hypersensitiveness and inflammatory changes in the protoplasmic 
elements of the soft fibrils, modified in manifestation by the char- 
acter of the structure itself. With such a destructive, deadly dis- 



HYPERSENSITIVE DENTINE. 200, 

order as caries working at its vitals, no portion of the structure of a 
tooth can be in a healthy state, for although teeth have not the 
complex and vascular formation of the soft tissues, we cannot con- 
sider these organs as made up of dead, inert matter. 

Denudation of portions of the tooth, its loss of a part of that 
which should form any of its investing protection, must subject it 
to unnatural conditions. If the gum has receded at the neck, that 
simply means that the tooth is exposed to new environments and 
strange perplexities that cannot be otherwise than exasperating. 
Under the stress of their provocation it assumes an added sus- 
ceptibility, and becomes more and more liable to attacks of external 
agents. All the dentine is thus affected, and it becomes tender, 
sensitive, responsive to any provocation. This, as in the case of 
caries, proceeds by continuity of tissue to the pulp, which also 
becomes irritable and inflamed, so that there is an immediate 
response to thermal changes, to the presence of acids or sweets, 
and even to the finger nail or quill toothpick. Metal toothpicks are 
almost always irritating to the teeth. 

Vitiated secretions are also a cause of sensitive dentine. 
The secretion of the somewhat specialized mucous follicles at the 
gingival margin is sometimes, through neglect of the teeth and the 
presence of fermenting debris, of a degenerative type. This secre- 
tion becomes acid, and in this state is highly irritative to the cervix 
of the tooth. Or the white deposit which is so frequently found 
surrounding the tooth at its neck, and which is made up of decom- 
posing matter undergoing fermentation or putrefaction, may be the 
cause of the irritation. The resulting acid may dissolve out some 
of the lime salts at the cervix, where the enamel is very thin, and so 
lay bare the dentine, which will thus be made specially irritable. 
Some of the most sensitive dentine encountered by the operator is 
the result of this acid degeneration or formation. 

The teeth are sometimes set on edge by the use of acids. 
This means softening of the superficial portion of the tooth, and a 
hyperesthesia, or its analogue, of the dentine. The sensation 
referred to is not a distinct pain, and it usually passes away with 
the provocation, but it is a definite feeling of responsiveness in 
dentine. The same kind of impression may be induced by reflex 
action, when a saw is filed or strong cloth is torn. 

15 



210 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XLVL 
TREATMENT OF HYPERSENSITIVE DENTINE. 

It has been affirmed that if a tooth that is in a healthy condi- 
tion is insensitive, a return to that state after diseased action should 
carry with it freedom from responsiveness. While this may be 
true, it is not always possible in dental practice to secure this result. 
In cases of caries it is impossible to induce a healthy state except 
by excision of the diseased part, as in necrosis of bone; and it is 
from the pain of that operation that we seek immunity; hence the 
only hope of the dentist is in securing an artificial anesthesia of the 
part. This may be readily accomplished, as in the other tissues, by 
inhibiting and stopping all nervous currents through general anes- 
thesia. But such methods are prohibited by the circumstances of 
the case. We do not wish to obtund all sensibility, but only to 
overcome that of a small part. 

The ordinary local anesthetics might be employed, and they 
would completely answer all demands were that which we wish to 
make insensitive supplied with bloodvessels and nerves. Unfor- 
tunately for our object, this is not the case with the teeth. Theirs 
is not the structure upon which local anesthetics act, and hence the 
latter are of but doubtful utility. When cocain was first discovered 
it was believed by many that the dental millennium had surely 
arrived, but that agent has been found powerless to benumb non- 
vascular tissues. This class of remedies may therefore be dismissed 
from consideration, because while they may under certain condi- 
tions inhibit nervous currents in tissues that have a nervous supply, 
they are inefficacious when that is lacking. Cocain will obtund a 
pulp that is exposed to its influence, but it is ordinarily powerless 
upon dentine. 

We are thus obliged to fall back upon specific remedies, or 
those whose therapeutic action is not thus limited. We know that 
the protoplasmic dentinal fibrils, when in an irritable state, or when 
made responsive by certain pathological conditions, will convey 
painful impulses along their course and deliver them to the 
cerminal nerve filaments of a more or less inflamed pulp. If, now, 
these afferent waves of irritation can be cut off at any point before 
reaching the sentient centers, immunity from pain will thereby be 






TRExVTMENT OF HYPERSENSITIVE DENTINE. 211 

secured. This can be done by a general anesthetic that paralyzes 
sensory filaments and trunks, or it could be accomplished by the 
application of a local anesthetic directly to the pulp itself. Both of 
these, for reasons already given, are impracticable, and it leaves the 
work to be done upon the only other connecting link between the 
dentinal periphery and the brain. 

If the dental fibrils themselves can be put in such a state that 
they will no longer carry impulses to the pulp, that tissue cannot 
transmit any to the afferent nerves which carry them to the nerve 
centers. 

Fig. 57- 



! 

f. 







, 



>- 



" 



Termination of the Dentinal Tubuli. 



a, Enamel; d, Dentine; c, Line of junction of enamel and dentine, — first calcification of tooth 
tissue; interglobular spaces. (Andrews.) 

There are two ways of accomplishing this, neither of which is 
entirely satisfactory in its results. The first is by producing some 
temporary physical change in the character of the fibril that will 
prevent its receiving an impulse, and the second by subjecting it to 
some medicinal agent that will paralyze its transmitting function. 

There are perhaps two other methods of accomplishing the 
same thing which should be included in the list of methods to be 
employed, and they will be duly considered. They are, first, the 
exercise of such care and gentleness, with the use of such perfected 
instruments as shall arouse no irritating pain waves; and, second, 
the employment of such general prophylactic remedies and 



212 ORAL PATHOLOGY AND PRACTICE. 

measures to fortify the system as will enable it to resist them, 
or steel it against their reception. 

The physical agents which are practicable will be such as will 
temporarily change the material characteristics of the fibrillse, and 
of these the most important are heat and cold. 

Heat may act either by raising the temperature above the point 
of susceptibility, — which is impracticable, because it is of itself a 
painful process, — or by so changing the matter of the fibrillar 
through desiccation, or drying out, as to make them incapable of 
conveying impulses. It is readily conceivable that, a cavity being 
isolated by the use of a rubber-dam, a current of hot air may be 
effectual in so changing the physical structure of a fibril, by 
abstracting a part of its water, as to debar all reception or trans- 
mission of nervous or other impulses. This is perhaps the most 
simple of all methods for obtunding sensitive dentine. 

The use of cold, or refrigeration, will be equally effectual by 
benumbing or paralyzing the fibrillse. If an ether or rhigolene 
spray is directed upon the tooth cavity, or even upon the tooth 
itself, until the temperature is reduced sufficiently, it will be com- 
paratively irresponsive. This would without doubt be the most 
perfect obtundent, were it not that the effective use of the agent 
is of itself too painful in its application. There is also danger that 
the pulp tissue may be permanently injured through degenerative 
processes inaugurated by the shock of the cold. A severe inflam- 
mation may be the result of the application of the ether spray for 
too long a time. Hence this agent has never been used for obtund- 
ing purposes, except in extreme instances. 

The medicinal agents that have been employed in attempts to 
overcome dentinal hypersensitiveness are almost numberless. 
General and local anesthetics, stimulants and anodynes, excitants 
and sedatives, acids and alkalies, with many drugs of altogether 
indefinite and unknown therapeutic value, have been persistently 
recommended. The whole matter has generally been one of 
empiricism. It would seem that, so far as our present knowledge 
goes, anesthetics, whenever locally applied, have little direct effect 
upon dentinal tissue. All such remedies have a selective power, 
and affect nervous tissue alone. The dentinal fibrillar while they 
do not contain any nervous filaments, yet comprise the elements of 
such tissue ; and it cannot be positively affirmed that they are not, 



TREATMENT OF HYPERSENSITIVE DENTINE. 213 

under certain conditions, amenable to anesthetic action. But we 
know that they are not ordinarily so, and hence the agents referred 
to have proved as inefficient as might have been anticipated. 

Certain sedatives, anodynes, and narcotics, like preparations of 
opium, cannabis indica, and chloral hydrate, have been effective in 
certain instances, but it is not at all certain that they did not work 
through other tissues, and thus act indirectly instead of directly. 
Some cauterants are effectual, but to a limited depth. Thus nitrate 
of silver, or chromic acid, or carbolic acid, will obtund, but only to 
the limited depth to which they reach. They certainly destroy the 
fibrillse completely as far as their action extends, but that action is 
not really obtunding; it is extinction. 

In the harmless coagulation of the albuminoid contents of the 
dental tubuli would seem to lie the surest road to success. 

There are coagulating agents that thus obtund, like chloride 
of zinc, but it is too often at the expense of quite as much suffering 
as they save, leaving out of consideration the dangers to which 
the dental pulp is exposed by the use in its proximity of active 
escharotics. If coagulation could be accomplished without per- 
manent injury to the tooth structure, and would reach deep 
enough to allow of effective excavation, the agent that accom- 
plished this without pain would be the long-sought desideratum. 
That drug has not yet been discovered, nor can we be sure that it 
ever will be. Certain it is that until it is sought for in an intelli- 
gent, scientific manner, it will remain a secret; for the illiterate, 
untaught ignoramuses who have in the past been mainly respon- 
sible for the quack preparations sold at an extortionate price, and 
who have not sufficient pharmacal knowledge to save them from 
compounding the most glaring chemical incompatibles, are not 
likely to be the discoverers of that which so many competent men 
have sought in vain. 

Cataphoresis, which is the transfer of medicaments into the 
deeper parts of tissue through the diffusive power of an electric 
current, seems to promise something in this direction. It is not 
recently acquired information that has taught us that when a drug 
is applied to a tissue upon the positive electrode of a battery, the 
negative being placed so that the current will traverse the organ 
to be affected, it will carry with it the remedy; this principle has 
been quite extensively employed in general medicine, and with good 



214 0RAL PATHOLOGY AND PRACTICE. 

results. To make the remedy in cataphoric medication effective it 
is not sufficient to carry it deeply into the dentine ; it must be trans- 
ferred to the pulp itself, and to the accomplishment of this the hard 
dental tissues present difficulties not met with in other organs, in 
their relatively low vitality and their comparative impenetrability. 
Yet practical experience seems to point to the indisputable fact that 
cataphoric transference does take place, but whether with sufficient 
readiness and rapidity to make it all that can be desired remains to 
be definitely established. No one will dispute the assertion that in 
the cataphoric transference of such topically applied remedies as 
cocaine and morphine better results have been secured than in any 
other of the thousand proffered methods of obtunding sensitive 
dentine. But its employment requires a cumbersome and expen- 
sive apparatus, troublesome alike to operator and patient, and its 
results are by no means uniform. While, therefore, every progres- 
sive operator should use it, it is not now to be considered a finality. 
Its application must be simplified and its effects made positive by 
further experimentation before it can be so accepted. Good men 
are investigating it, and it is to be hoped that in it will eventually 
be found that which is so highly desirable. It cannot be forgotten, 
however, that good men have before this cried, "Lo, here! Lo, 
there!" only to meet final disappointment and defeat. 

Prophylactics have proved of great service in the dental operat- 
ing room. They are of sedative nature, and reduce general nervous 
irritability, thus preventing or obtunding nervous shock. They 
have not been as much used as their merits demand, because most 
dentists have either been lacking in the medical knowledge neces- 
sary to their most intelligent use, or have not felt themselves war- 
ranted in administering general remedies. The first of these 
causes, if it exists, should be at once removed by study, and the 
last eliminated by a proper amount of self-confidence. The time 
for administering such remedies is a few moments before com- 
mencing any painful operation, the exact interval depending upon 
the nature of the drug. A few whiffs of chloroform or ether, not 
enough to induce any functional disturbance whatever, will fre- 
quently be of use, but their influence will not last long. Twenty- 
five grains of potassium bromide in water will be more persistent, 
and usually quite as effective. Syrup of lactucarium, in teaspoon- 
ful doses, has been employed with good effect ; or tincture of bella- 
donna, administering from five to twenty drops. 






TREATMENT OF HYPERSENSITIVE DENTINE. 215 

Sulphate of morphia, in doses of from a quarter to half a grain, 
has been frequently used, but its action upon some people is a little 
uncertain. The fluid extract of Jamaica dogwood may be substi- 
tuted for this, and five to twenty drops given in a little water. 
The full dose of the drug is from a half to two fiuidrams. The 
author has not for several years been without aromatic spirits of 
ammonia in his case, and whenever there is unusual nervous irrita- 
bility he administers from thirty to sixty drops of it in water. If 
there arises the necessity, a hypodermic dose of from one-eighth to 
a quarter of a grain of morphine may be given. This is usually 
effectual in quieting all nervous excitability and making otherwise 
insupportable operations comparatively tolerable. The proper 
dose of this drug, combined with atropine or strychnine, may be 
readily obtained in tablet form, and should always be kept at hand. 

Hypodermic medication has not been as much employed in 
oral practice in the past as it should have been. 

But, when all is said and done, the main dependence of the 
judicious dentist will be upon a gentle hand and sharp instruments. 
It is barbarous to employ in a sensitive tooth any tool that is not 
in the best possible order; while the operative dentist who for a 
moment allows himself to forget the consideration that is due to a 
sensitive, timid, shrinking patient, who will become in the least 
degree careless or callous, and thus give unnecessary pain, is 
unworthy his vocation. In excavating a sensitive tooth he should 
invariably put on the rubber-dam, and dry out the cavity as far as 
possible. Then he w T ill find a great deal of relief in the employ- 
ment of many of the remedies already mentioned, and especially 
in the use of some of the essential oils, like cassia, cloves, or 
eucalyptus, securing penetration by means of the hot-air blast. 
A mixture of equal parts of sulphate of morphia and gum camphor 
may be found useful for this purpose in some instances. Or he 
may apply tincture of aconite dilute, or any other favorite remedy, 
always remembering that its effectiveness will be greatly increased 
by thoroughly drying the cavity of decay, and by the hot-air 
current. 

For those who wish a cocain preparation that is effective, the 
following is given. It should not be forgotten that this is a ten 
per cent, solution, and when used hypodermically less of it should 
be injected: 



2l6 ORAL PATHOLOGY AND PRACTICE. 



Atropine, 


T V grain; 


Strophanthine, 


Vs " 


Cocain mur., 


50 " 


Carbolic acid, 


10 " 


Oil of caryophyllus, 


3 minims ; 


Dist. water, 


1 ounce. 



The following formula has been recommended by Professor 
Peirce as effective: 

ty — Cocain mur., 5 grains; 

Carbolic acid, 20 " 

Chloroform, */ 2 dram; 

Muriatic acid, 10 minims; 

Alcohol, 2 drams. 



CHAPTER XLVII. 



SECONDARY DENTINE, PULP NODULES, AND 
CALCIFICATIONS. 

These, although different manifestations, are parts of the same 
process. They have their origin in the same disturbed function. 
They are the result of deranged neural currents and of some per- 
version of nutrition which induces a formation of dentine in abnor- 
mal quantities or in an anomalous position, through the undue 
activity of the odontoblast cells under the excitement of just 
enough of irritation to act as the proper stimulant. All of these 
products have the general structure of dentine, although it may be 
considerably modified. (See Fig. 58.) They are not usually 
found as mere calcific, structureless calculi, but are organized by the 
unduly excited odontoblast cells, whose normal activity continues 
through life. 

The odontoblasts are not found exclusively upon the periphery 
of the dental pulp, any more than osteoblasts exist alone in con- 
nection with periosteum. The latter may be found inside the body 
of the bone, and may be the initial points for new growths after 
operations or accidents. The former may exist or be developed 
within the pulp tissue, and under the special stimulus that was 
perhaps responsible for their formation may commence functional 
activity, with the consequent organization of segregated spicules of 
dentine, and these may continue to grow until they assume the form 



SECONDARY DENTINE, PULP NODULES, AND CALCIFICATIONS. 2\J 

of the usual pulp nodule. Sometimes this form of calcification may 
begin at many points within the pulp, and may impart to that of a 
freshly extracted tooth a gritty, sandy sensation when it is rubbed 
between the finger and the thumb. At other times there is an 
agglomeration into one or more large concretions. 

When the unwonted functional activity is at the peripheral 
pulp borders, the new formation will probably be attached to and 
form a kind of hypertrophy of the ordinary dentine of the tooth. 
Sometimes this will be so continued that it will almost entirely fill 

Fig. 58. 





Formation of Pulp Stones. (Andrews.) 



the pulp chamber, and even extend down into the root canal. 
An examination of an extracted tooth affected with this condition 
will show by its complete or partial attachment to the normal 
dentine, or by its independence of it, where was the commencement 
of the new growth. 

The "pulp stones," or formations of dentine that take place 
within the substance of the pulp, sometimes contain chambers not 
unlike the "interglobular spaces" of the tooth. These impart an 
appearance of bone, and the new formation is analogous to true 
"osteo-dentine." It may even have open canals that cause it to 



218 



ORAL PATHOLOGY AND PRACTICE. 



assume the appearance of vaso-dentine. As might be inferred from 
the circumstances under which it is deposited, its structure will be 

Fig. 59. 




Secondary Formations in the Tooth of a Whale. 



Fig. 60. 







Wounded Tusk of Elephant. 

a, Point of entrance of musket ball through the alveolar walls when the animal was young ; 
b, The ball carried down and imbedded in the ivory or dentine by the growth of the tusk. (From 
a specimen in the Buffalo College Museum.) 

quite irregular and unmethodical. The canaliculi, or dentinal 
tubuli, will be involved, convoluted, and irregular. More or less 



SECONDARY DENTINE, PULP NODULES, AND CALCIFICATIONS. 2IO, 

Fig. 6i. 




A Representation of the Tusk shown in Fig. 60, with a Section Removed to show 
Secondary Formations in the Pulp Chamber above the Ball. 
a, Cervix of tusk ; b, c, d, e, Masses of secondary formation. 



220 



ORAL PATHOLOGY AND PRACTICE. 



of the calcified mass may be hyaline, but the structure, when care- 
fully studied, will be found to be essentially dentinal. 

The study of comparative dental anatomy will materially 
assist in a comprehension of these anomalies. In certain animals 
secondary dentine, or tooth-bone, is very common. This is 
especially the case with some of the monophyodonts. The per- 
sistent pulp chambers of the sperm whale (Physeter macrocephalus) 
are very frequently lined or partially filled with secondary 
dentinal formations, and some of them make very beautiful objects 
when polished. (See Fig. 59.) The long incisors of the elephant, 
the so-called tusks, are frequently wounded by the hunter near their 
insertion, the bullets remaining in the persistent pulps. This may 
result in the destruction of the vascular portion of the tooth, but 



Fig. 62. 




Fossil Fragment of the Tusk of Elephas primigenius—in^. Hairy Mammoth — which 
had been partially fractured during llfe and repaired and strengthened by 
Secondary Deposits. 

The fracture was across the base at a ; the part between the lines at b and c was a second- 
ary deposit. (From a specimen in the Buffalo College Museum.) 

much more frequently the consequence is the deposition about the 
wound of secondary dentine, which perhaps will entirely inclose and 
segregate the original cause of irritation, and form septa across the 
pulp chamber. With the continuous growth of the tooth or tusk 
this is carried forward, until, perhaps many years subsequently, 
when the animal is killed and its tusk falls into the hands of the 
ivory cutters, the original bullet, with the secondary formation 
about it, is found in the solid ivory, perhaps one or two feet from 
the skull. (See Figs. 60 and 61.) 






SECONDARY DEXTIXE, PULP XODULES, AXD CALCIFICATIOXS. 221 

Nature sometimes throws out a layer of secondary dentine to 
protect the pulp from slowly advancing caries, or erosion. The 

formative cells at the periphery of the threatened portion of the 
pulp are by the irritation stimulated to increased functional 
activity, and a kind of hypertrophy of dentine is the result. Prac- 
titioners have sometimes seen this take place under a plastic rilling 
that had been inserted over a nearly exposed pulp. In the course 
of a few years this perhaps became sufficient support for a solidly 
impacted metal filling. This is the result hoped for in all instances 
of ordinary capping. Fractured teeth have been known to be 
united by a secondary growth of dentine, though these instances 
are probably few in number. 

The formation of so-called pulp stones and secondary dentine 
is a much more common occurrence than is usually imagined. The 
examinations of the pulp chambers of extracted teeth in the teach- 
ing of operative technics in some of the colleges, shows that a con- 
siderable proportion of teeth are thus affected. The late Prof. 
A. P. Southwick, of -Buffalo, who was one of the most observant 
and successful of technic teachers, believed that from sixty to 
seventy per cent, of extracted teeth show some form of it, but as 
this applies chiefly to such as have been extracted for diseased con- 
ditions, probably it would not hold good universally. 

The formations within the pulp chamber are sometimes the 
cause of considerable local irritation, but neither the objective nor 
the subjective symptoms of these conditions are sufficiently distinc- 
tive to afford reliable means of diagnosis. When they are of rapid 
growth the pain may be of an acute character, but they do not 
under ordinary circumstances induce any breaking down of pulp 
tissue, nor do they bring about any serious complications. Usually 
the suffering is of that subacute nature that is hardest to locate. 
It presents no special distinguishing characteristics, and a diagnosis 
can only be safely made through exclusion. When it is certain that 
the pain arises from nothing else, it may be attributed to secondary 
formations. It might, by the superficial observer, readily be mis- 
taken for facial neuralgia, but it is not, like that, paroxysmal or 
periodical. Xor is it so acute or so intense in its nature. 

The presence of pulp stones will not usually be suspected until 
they are discovered through pulp exposure. Xot infrequently they 
will seriously embarrass the dentist in his efforts at pulp devitali- 



222 ORAL PATHOLOGY AND PRACTICE. 

zation and extirpation. Sometimes in their presence it is with the 
utmost difficulty that even arsenous acid can be made to produce 
its characteristic effect. Why this should be the case to such a 
marked degree it is impossible to say, as the secondary formation 
does not usually make an entire septum in the pulp chamber. 
That it may completely bar the proper filling of the roots of a 
tooth is more conceivable, for the growth may be so attached to the 
ordinary dentinal walls as to make its removal very difficult. It 
may form such an obstruction in a root canal as will absolutely 
forbid the passage of an instrument. In such instances the Papain 
digester, as recommended by Professor A. W. Harlan, may be made 
to serve a specially useful purpose in removing portions of the 
devitalized dental pulp which are beyond the reach of instruments. 
In the past there has been no resource save the slow and uncertain 
process of sloughing, which implies an infected root canal. 

The presence of secondary formations, then, will only be 
positively known when it is too late for anything but removal, when 
this is practicable. If they are floating in the pulp chamber this 
will not be a difficult matter. But if they are attached to the 
dentinal walls it may be impossible. It is not a safe practice to 
attempt to drill them out, nor in all cases would this materially 
assist in the subsequent treatment and filling of the root. The 
operative dentist will be obliged to take them out by enlarging the 
opening into the pulp chamber when this is practicable, or to use 
sufficient time thoroughly to sterilize any fragments of remaining 
pulp tissue, and then to fill as best he can, using some plastic 
material for the pulp chamber. 



CHAPTER XLVIII. 

HYPERCEMENTOSIS. 



Hypercementosis is the analogue of hyperostosis, or exostosis, of 
bone. Technically it is a tumor, but always of benign growth. It 

is an hypertrophy of the cementum, and has its origin in some form 
of irritation that is just sufficient to stimulate the pericementum to 
an abnormal activity. (See Fig. 63.) It may be local, and affect 
but one tooth, or the irritation and stimulus mav be so o'eneral as to 



HYPERCEMENTOSIS. 



223 



induce an excessive deposit of cementum in some form upon all, or 
nearly all, the teeth of either jaw. (See Fig. 64.) It may even 
be more comprehensive than that, and involve the osseous tissues. 
Instances have occurred in which hypercementosis and hyperostosis 
existed together, with not only enlargement of the roots of all the 




Hypercementosis of the Roots of a Lower Molar showing Stimulation 
of the Entire Pericemental Membrane. 

teeth, but of the whole alveolar process of the bone as well. Nodules 
of exostosed bone may sometimes be felt along the alveolar portions 
of the lower jaw especially, and these are apt to be associated with 
expansion of the roots of the teeth from hypercementosis. (See 

Fig. 65.) 

Fig. 6a. 




General Pericemental Hyperplasia. Teeth Successively Lost by One Patient. 

The Two on the Right were Fused together by the Hyperplastic Cementum. 

(Practice of Dr. William Jarvie.) 

The condition is not one that presents very special pathogno- 
monic symptoms. Unless it is accompanied by hyperostosis, there 
will be no external indications of its existence. Nor is it provoca- 
tive of much pain. Hence its diagnosis is at times difficult, or even 
impossible. There may be a feeling of pressure and general un- 
easiness in the teeth affected, but it will not be sufficient to furnish 
a diagnostic sign. There are no special complications, and hence 



224 



ORAL PATHOLOGY AND PRACTICE. 



the condition is not one of great pathological importance. Its chief 
import to the practicing dentist lies in its being an impediment to 
extraction,) and when that is imperative may make it necessary to 
cut through the investing alveolar process before the tooth can be 
lifted out. This will only be called for at the cervical constricted 
portion above the expanded part of the root. There will have 
been a resorption of the investing bone sufficient to accommodate 
the hypertrophy itself, and the cutting through, or removal of a 
part of the constricted superficial alveolar process is but a simple 



Fig. 65. 





Nodular Hyphrcementosis with Accompanying Hyperostosis. 

a, Osteophytes upon the external alveolar surface; b, Irregular cemental growth, involving 
both buccal roots ; c, Cementum nodules. The teeth were so bound together by the interlock- 
ing of the cemental growths that all three unavoidably came away together with the exertion of 
but moderate force, causing an opening into the antrum. (Practice of Dr. G. C Daboll.) 

operation, and is very much preferable to a long struggle to effect 
expansion in continued efforts to extract the tooth, with the liability 
to its accidental fracture under the forceps. 

Microscopical sections of portions of hypertrophies of the cemen- 
tum show that they have the true cemental structure, and there is 
no special line of demarkation visible between the new and the old 
formation. Pigmentation, or coloring, is not uncommon, its most 
usual form being a deep yellow or light brown tinge. The cemen- 
tum corpuscles are often unusually large, so that the nutrition of 
the hypertrophied and original tissue is very well carried on, for 
perhaps obvious reasons. A clinical and microscopical study of 



DISCOLORED TEETH. 225 

the pericementum in these conditions has not hitherto been made. 
When this is undertaken further light upon this interesting subject 
will without doubt be afforded. 



CHAPTER XLIX. 
DISCOLORED TEETH. 



While the remedial measures for the relief of discolored teeth 
belong rather to operative dentistry, and are outside the scope of 
this work, yet a little may be said concerning the cause of dis- 
coloration, which may be due either partially or entirely to patho- 
logical conditions. People sometimes present themselves to the 
dentist with the request that an objectionable color of the whole or 
parts of the teeth may be discharged, when it is plainly evident that 
it is congenital. Some people have yellow, and some dark teeth 
naturally, and no skill is sufficient to alter this without material 
injury. The leopard cannot change his spots, nor the Ethiopian 
his skin. 

But there are pigmentary deposits upon the surface, and stain- 
ing which penetrates to a little depth, that it is possible to remove. 
Of these the most common is the so-called "green stain" so fre- 
quently found on the teeth of children, and the analogous brown or 
reddish-brown pigmentation on those of older growth. It has no 
special pathologic signification, and may readily be removed by 
tinct. iodine and pulverized pumice. (See Fig. 39.) Dead dentine, 
the tubules of which have become filled with pigmentary matter, 
may be bleached by chemical agents. Usually these deposits, either 
upon or within the substance of the teeth, are of a yellow or dark 
color, but in some instances the teeth are turned to a bright blue, 
or even an intense green. Workers in different metals may have 
their teeth stained by minute particles. This is especially the case 
with brass, nickel, and copper workers. When this is superficial 
it may be readily removed, but when it has penetrated the substance 
of the tooth it presents greater obstacles. 

It is not usually the case that a tooth containing a living pulp 
is affected by anything beyond mere shallow exterior discoloration. 
There may be congenitally maculated spots, or atrophied regions 

16 



226 ORAL PATHOLOGY AND PRACTICE. 

that become pigmented, but any material changes of color are 
-usually associated with a devitalization of the affected tissue. As 
the consequence of a sharp blow, and sometimes too protracted 
or severe dental operations, a tooth has been known to as- 
sume a bright pink appearance. This is, however, the result of 
death of the pulp. While the red blood corpuscles are much too 
large to enter the dentinal tubules, their stroma may be ruptured 
and the hemoglobin may penetrate the tubuli, giving the red tint. 
Subsequent changes in this substance may produce a gray or brown 
color, which finally becomes fixed as a very dark or blackish tint by 
the action of iron or sulphur. This is more apt to be the case in man 
than in woman, because the percentage of accidents is somewhat 
higher. The changes are analogous to those that take place when 
one has a "black eye," but as there are no absorbents to take up the 
•decomposed blood, it remains a black or dark color. 

The dentinal fibrillar themselves may, instead of being sloughed 
<out, remain, and after desiccation or drying undergo slow retro- 
gressive changes that leave the dentine a dirty yellow or dark 
ibrown color. Foreign matter may enter the tubuli, and there 
slowly become carbonized, and thus form another cause of dis- 
coloration. Substances used in filling may impart a stain to the 
devitalized dentine. Oxidation, or other chemical changes going 
■on in metals used for posts to assist in the retention of fillings, may 
induce pigmentation more brilliant than ornamental. Thus a piece 
of copper has been known to impart to a whole crown a beautiful 
green color, while nickel has given a color approaching turquoise 
blue. 

The most effective means for the discharge of the yellow or 
dark colors is by the use of chlorine gas. Oxygen is really the 
active agent, but the most convenient way to generate it is by the 
.use of some preparation that will liberate chlorine gas, and this, in 
the presence of water, unites with the hydrogen and sets free 
-oxygen, which accomplishes the work. Peroxide of hydrogen and 
pyrozone, both of which loosely hold in solution an extra volume 
of oxygen, are also used for the purpose. It is sometimes neces- 
sary to repeat the bleaching a number of times, for the discolora- 
tion is likely to return until all the colorization changes have ceased. 

As it is difficult to force the bleaching agent very far into the 
• dentinal tubuli, it is usual to cut out all the discolored tissue that it 



CONGENITAL IMPERFECTIONS OF ENAMEL. 22J 

is possible to spare before commencing the process. The bleach- 
ing interferes with the integrity of the tissue, and weakens the 
tooth. Large contour restorations, after this process, are therefore 
likely to fail; this fact, with the liability to recurrence o^ the pig- 
mentation, has made crowning rather to be preferred in many cases. 



CHAPTER L. 

CONGENITAL IMPERFECTIONS OF ENAMEL. 

While enamel is organic in the sense that it is the product of 
function or growth, its proportion of living matter is so small that 
natural reparative processes or spontaneous degenerative changes 
are practically impossible. Its proximate principles are inorganic, 
though of organic origin. In the eruption of the tooth all connec- 
tion between the enamel and its formative organ is necessarily de- 




roTAL Lack of Development of the Crowns of the Teeth. Cast of the Upper 

Jaw of a Young Man. The Peculiarity is the Result of Inheritance. 

(From a case in practice.) 

stroyed. Its relations are such that there can be no nutritive circu- 
lation, and hence practically it can undergo no changes except such 
as are retrogressive in their nature. And yet, because of its con- 
nection with vital tissue, the proportion of living matter in its 
composition, which though small, is constant, as well as the fact of 
its genetic origin from bone, of which it is a modification, its con- 
sideration as inorganic is forbidden. 



228 



ORAL PATHOLOGY AND PRACTICE. 



These facts indicate that enamel degenerations are not, strictly- 
speaking, pathological, and that their treatment must be from a 
chemical and mechanical standpoint, rather than from one which is 
medicinal or vital. By this it is not meant that therapeutic agents 
are never to be employed, or that special remedies may not some- 
times be useful. But such agents should either be directed toward 
the stimulation of constitutional functional activity, or the neutral- 
ization of deleterious products, the result of some vital derange- 
ment. Thus general alterative treatment may change the char- 
acter of environing secretions, or local applications may make them 

innocuous. 

Fig. 67. 




Cast of the Lower Jaw of the Qase Represented in Fig. 66. A Very Thin Edge 
of Enamel Appeared at the Cervical Margins of a Few of the Teeth. There 
was None upon the Occlusal Surfaces, the Dentine being Exposed and of a 
Light Amber Color. 



The imperfections of enamel may be divided into two classes: 
those which are formative or natural, and those which are deriva- 
tive or acquired. The first of these will consist of the structural 
imperfections produced by aberrant conditions during the process 
of development, while the latter will be the result of subsequent 
abnormal and unnatural environments, or the subjection of the 
teeth to exceptional conditions. The first named will be apparent 
when the teeth are erupted, while the last will only be observed as a 
natural effect of the anomalous surrounding circumstances. 

It has already been asserted that enamel is a modification of 
bone, composed of precisely the same elements, though in varied 



CONGENITAL IMPERFECTIONS OF ENAMEL. 



229 



proportions and modified structure. (See Chapter XXII. ). Its 
growth is a physiological process, and is subject to natural law. 
Pathological derangements may, however, induce such deflections 
of nutritive currents, or such structural imperfections in the forma- 
tive enamel matrix, as may result in defects or faults, or even 
entire absence of enamel. It is readily conceivable that any func- 
tional disturbance of a grave character might bring this about, but 
as the tissue is of epiblastic origin, any disease which materially 
involves epithelial structure, it might easily be imagined, would, 
during the formative period of enamel, leave upon it an indelible 

Fig. 68. 




Figs. 66 and 67 as They Appeared in Occlusion. The Condition was that which 
was Natural in this Case and Not the Effect of Wear. 



mark. Hence to the eruptive diseases of childhood have been 
ascribed, correctly or incorrectly, very many of the imperfections 
which are found in enamel when the tooth is erupted. That this is 
the sole cause the many varying phenomena would make very im- 
probable, to say the least. 

It is sometimes the case that no crown whatever is developed, 
and instances have been known in which all of the permanent teeth 
were practically crownless, although the roots were fully grown and 
of the ordinary size, and the alveolar process was of the usual pro- 
portions. Such a case in the practice of the author is represented 
in Figs. 66, 67, and 68. The peculiarity in this instance was 



23O ORAL PATHOLOGY AND PRACTICE. 

hereditary, inclining to follow the law of atavism, and, so far as the 
history could be traced, appearing usually in not more than one 
individual in any generation. The cementum and dentine of the 
roots were normal, while the enamel was either wholly lacking or 
existed but as a friable edge at the cervix of a very few of the teeth. 

In this instance, no enamel organ could have developed, or at 
the best it must have been rudimentary. The results could not 
have been produced by any eruptive disease, nor any sudden 
constitutional crisis the result of nutritive changes. The incep- 
tion of the morbid anatomical condition must have been pre- 
natal, and so the whole was congenital. As in cleft palate, there 
must have been deficiency in formation, and the plastic organ 
which should have been the genetic source of enamel growth 
was either functionless or practically wanting. The absence of an 
enamel organ would change the whole character of the dental 
follicle, and the dentinal papilla would be functionless, so far 
as the development of that part of the dentine which is in relation 
with the enamel is concerned. But as that tissue is mesoblastic 
in its origin, when the cementum was organized through the 
growth of pericementum the function of the dentinal papilla 
below the crown would not be materially interfered with and 
the root would present a natural appearance. 

That which was general in the instance cited, might in other 
cases be local or partial, and this would account for the total or 
limited loss of enamel in individual teeth. Such limitation of the 
evolution of the enamel organ, or imperfections in it, would be 
most likely to appear along its internal epithelial border, or 
that which initiates the process of enamel formation, and hence 
it is that the incisive portions are those which are most imper- 
fect, while that which* is later organized may be quite normal in 
structure, a condition that is commonly observed in aberrations 
of the six anterior teeth and the first permanent molar. (See 
Fig. 69.) The influences may affect the whole enamel, though 
in a less degree in the later stages of formation. (See Fig. 70 
and Fig. 71.) 

That the exanthematous diseases may exert a grave influence 
upon enamel formation few will dispute. They must affect all 
epithelial tissues, and accordingly, aside from or as a part of the 
general degeneration that accompanies them, there may be observed 



CONGENITAL IMPERFECTIONS OF ENAMEL. 



231 



a falling of the hair, with the appearance of atrophied spots, and 
in some cases furrows in the nails, bearing some analogy to those in 
the teeth. It would not, however, be anticipated that they would 
present precisely the same phenomena with those which are 



Fig. 69. 





Furrowed Enamel, with Malformations 

of.the Crown of the Tooth. 

(Tomes.) 



Entire Absence of the Enamel from: 

that Part of the Crown that is 

First Formed. That Later 

Developed is Perfect. 



Fig. 71. 




Furrowed Enamel, consisting of Alternate Grooves and Ridges of More 
Perfect Tissue. (Tomes.) 



Fig. J2. 



Fig. 73. 




Imperfect Enamel, showing Two Dis- 
tinct Series of Pits, with Perfect 

Enamel between them. 
(From American System of Dentistry.) 




Irregular Pits upon the Crowns of 

Teeth Ascribed to Eruptive or 

Exanthematous Diseases. 



congenital in their origin, and so the marks upon enamel pro- 
duced by the eruptive disorders through which the child may 
have passed during the period of calcification present indications 
of the interruption of nutrition, rather than entire absence of 



232 



ORAL PATHOLOGY AND PRACTICE. 



any formative enamel organ. They are confined to the enamel 
itself, and not at all, or but in a slight degree, affect the dentine 
beneath. They may exist as a kind of single pitted furrow across 
the face of the tooth, or there may be more than one such, show- 
ing successive attacks. (See Fig. 72.) Not infrequently they 
may appear as shallow, isolated indentations in the enamel, giv- 
ing it a rough, uneven appearance, and they bear some analogy 
to the cutaneous pits produced by smallpox. (See Fig. 73.) 

Fig. 74. 




Casts of the Edentulous Jaws of a Man of Forty-five Years who Never had 
either .Deciduous or Permanent Teeth. In Addition He was Without Hair 
on Either Head or Body, was Lacking in the Senses of Taste and Smell, and 
was Without Any Perspiratory System. 

As the degenerations considered in this chapter are either 
pre-natal in their origin, or are dependent upon general consti- 
tutional conditions which produce their characteristic effects be- 
fore the teeth are erupted, and hence in neither case can be 
diagnosed or anticipated until they shall have made their appear- 
ance, when it is too late for the adoption of any prophylactic 
measures, no course of treatment, aside from mechanical meas- 
ures, can be recommended. When the crowns are entirely 
absent, artificial ones may be engrafted, and when there are 
imperfections of enamel the roughness may, to a certain extent, 
be removed by the file or a corundum stone, and afterward care- 
fully polished, or the pits may be filled by the use of gold or 
porcelain inlays. 



ACQUIRED OR ACCIDENTAL IMPERFECTIONS OF ENAMEL. 233 

CHAPTER LI. 

ACQUIRED -OR ACCIDENTAL IMPERFECTIONS OF ENAMEL. 

The abrasions or erosions of enamel which appear subsequently 
to the eruption of the teeth must of necessity have a widely different 
origin from the imperfections that are formative or congenital. 

As the proportion of living matter in the constituent elements of 
enamel is proportionally so small, and as there can be no nutritive 
currents and consequent metabolic changes in structure because 
of the destruction of the organ which afforded nourishment 
during growth, any modifications or degenerations of that tissue 
after it is once formed must be the result of local causes and due 



Fig. 




1st year. 3d year. 6th year. 7th year. 8th year. 9th year. 10th year, nth year. 
Development of the Superior Central Incisors. (Broomell.) 

to environing conditions. There can be no reconstruction of 
that which has once been lost, nor can there practically be natural 
recuperation from the effects of diseased conditions. All changes 
must of necessity be, to all intents and purposes, retrogressive in 
their nature and the result of extraneous causes. 

Aside from caries and the results of accident, the degenerations 
of formed enamel must result from either attrition or chemical solu- 
tion. It is not meant to be asserted that theoretically there may not 
be structural changes, for these naturally inhere to all organic 
bodies, but practically they must be so infinitesimal in enamel 
that they cannot be reckoned as a factor worth mention in con- 
sidering the present subject. That the tissue does undergo 






234 0RAL PATHOLOGY AND PRACTICE. 

certain superficial modifications, the clinical experience of most 
experienced dentists will establish. There are times when it 
seems specially subject to wear and attrition. But as these 
conditions cannot be the result of functional action, they must 
be accidental and due to some special state of the oral secretions 
and fluids. 

That which has been denominated "mechanical abrasion," 
the ordinary wear of teeth, presents no unexplainable phenomena. 
Certain kinds of food abrade the grinding surfaces of the teeth 
very fast. Those of the early Indians of the Southwest were, 
in adult life, usually worn down nearly to the gums by the silicious 
covering of the corn which formed the principal article of their 
diet. Among our own people, when mastication must be ex- 
clusively done upon the anterior, teeth because of loss of the 
molars, in time the upper incisors are apt to become so worn 
and channeled as to present the appearance of, and by the laity 
b^ mistaken for, "double teeth." The tooth-brush may be re- 
sponsible for some of that upon the labial aspects, but aside 
from the evident results of attrition, there appear occasional 
furrows and concavities that are not congenital and that cannot 
be the consequence of any usual cause. Sometimes these occur as 
deep pits in the occluding surface of a molar, without a corre- 
sponding protuberance on its antagonist. The channels may be 
between teeth, where no brush could reach them. They are even 
found in the teeth of wild and domestic animals, the brush as a 
necessary cause being thus eliminated. Cases have been known in 
which upper incisors, for instance, have the appearance of being 
regularly and evenly chamfered from the cervical portion to the 
point, as if done with a flat file. In other instances there is a suc- 
cession of erosive channels or excavations, symmetrical and 
usually following the line of the gingival border. (See Fig. 76.) 
One peculiarity of this condition is that the surface left is smooth, 
and in some instances apparently polished. 

Very frequently the excavations are near the margin of the 
gum, and their edges may be too sharp and well defined to be 
caused by any common form of attrition, in some instances pre- 
senting a distinct undercut. They may be confined to a single 
one, or may affect a series of teeth. Usually they are found only 
upon the buccal or labial aspect, occasionally on the proximate, 



ACQUIRED OR ACCIDENTAL IMPERFECTIONS OF ENAMEL. 235 

and very rarely upon the lingual surfaces. They do not seem to- 
be necessarily connected with any special diathesis, for they are 
found in the teeth of people who show no indications of gout, 
rheumatism, or any of the diseases to which they have by some 
been attributed. No explanation has ever yet been presented 
that will account for all cases of abrasion. Chemical solution by 
mineral acids is not sufficient, because any acid sufficient to 
account for the erosion of the surfaces of incisors must 
manifest itself in other ways; besides, this at times 
occurs when the reaction of the oral secretions is 
not strongly acid. It has been attributed to electro-chemical cur- 
rents which produce electrolysis. The improbability — nay, more,, 
the absolute impossibility — of the existence of such currents in the 
mouth seems too apparent to need demonstration. There is no 

Fig. 76. 




Erosion of the Teeth. (Darby, from Burchard.) 

question that electrical currents are constantly being formed by the 
incessant chemical action and the different molecular changes that 
never cease in the oral cavity, but it must also be as true that they 
are as perpetually and as instantly dissipated. There can be no- 
closed circuits, nor any such thing as accumulation; and hence, 
while theoretically they may be present, practically they must as 
inevitably be powerless for either good or evil, vanishing on the 
instant of their birth. 

It seems to be true that while the acid reaction in some 
instances of erosion may be weak, so far as observation goes it 
always exists. It is well known that organic acids in their nascent 
state are most active. While, therefore, through fermentation or 
in a degenerative state of the mucous follicles an acid may by 
combination be formed in a circumscribed locality, and there, on the 
spot of its birth, have sufficient force to attack tooth substance, as 
soon as it becomes diluted and its affinities are partially satisfied 
it might give but a weak reaction when tested. In this fact may be 



236 ORAL PATHOLOGY AND PRACTICE. 

found a partial answer to some phenomena. But fermentative 
acids would not probably be formed upon the most prominent 
labial surfaces of incisors for instance, where they are most free 
from any foreign fermentable substance, and where they are 
constantly washed by the saliva and kept clean by the friction of 
the lips. 

The excavations or cavities formed by erosion bear some 
analogy to those in certain instances of caries. The loss of tooth 
substance is as positive, its attacks may be seen in the same 
localities and the form of the excavation is very like that in some 
kinds of superficial decay. (See Fig. Jj) But there the resem- 
blance ceases. Both may be the result directly of the decalcifying 



Fig. 77. 




Erosion of the Teeth on the Labio-Gingival Areas. (Darby, from Burchard.) 



action of some acid, but in caries there is infection and the action 
of both fermentative and putrefactive organisms, while no septic 
condition accompanies erosion. In caries there is the formation 
of minute caverns in the dentine, with subsequent crumbling of 
the friable tissue, leaving a rough cragged surface, while in 
erosion the bottom of the excavation is smooth, or even polished. 
(See Fig. 78.) Miller asserts that* even when calcining has re- 
moved all the organic material from the tooth, the eroded surface 
still retains this polished appearance, indicating that essentially 
the process is very distinct from the minute excavations of caries. 
A degenerative, acid condition of the secretions of the special- 
ized mucous glands at the gingival margins might, and probably 
does, account for some of the peculiar erosion that exists in such 
localities, but it offers no explanation for that upon the occluding 
or incisive edges of the teeth. Vital depression, an atonic condi- 
tion that offers a decreased resistance to degenerative changes, are 



ACQUIRED OR ACCIDENTAL IMPERFECTIONS OF ENAMEL. 2^J 

terms too vague and indefinite to be accepted as elucidations of 
such a condition as abrasion. 

We are simply reduced to the alternative of accepting explana- 
tions that do not explain, or frankly admitting that there is much 
in this condition which with our present knowledge is not com- 
prehensible. There are factors at work which we probably know 
not. That it is an external agent of some kind is proven by the 
fact that a protective filling, when well inserted, always screens 
the tissue that it covers. The wasting process may go on all 
about the filling, but it ceases beneath it. 

Fig. 




Erosion of the Enamel Surfaces of the Teeth Extending into the Dentine. 
b, Profile of the depth of the erosion in the left upper and lower central incisors. (Black r 
from Burchard.) 

In the absence of definite knowledge of the etiology of 
erosion, any positive prophylactic treatment cannot be laid down. 

Filling prevents penetration, but it does not in all cases 
debar extension. It forms the only effective operative treat- 
ment that can be pursued, for usually there is no polishing or 
cleaning to be done. If there is a distinctly acid reaction of the 
fluids of the mouth it shows that assimilation and nutrition are 
interfered with, and relief may be found in alterative remedies, and 
in change of climate, out-of-door exercise, or perhaps the use of 
tonics. Lime-water may be used as a gargle, and at night a 
spoonful of Phillips's milk of magnesia may be rinsed about upon 
the teeth and left there until morning, or until it is slowly dissolved 
off. Moderate friction of the gums with the brush, and massage 
with the ball of the finger, are always stimulating and useful. 



2$8 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LII. 
REPLANTATION; TRANSPLANTATION; IMPLANTATION. 

Replantation and transplantation are the insertion of an 
extracted tooth in a natural, and implantation in an artificial 
alveolar socket. Replantation is the replacing of a tooth in the 
same place from which it was, either accidentally or purposely, 
extracted. Transplantation is the removal of a tooth from one 
mouth to another. This was originally performed by placing the 
donor and receiver in the same room, and then extracting a dis- 
eased or decayed tooth from the latter and immediately substitut- 
ing it by one extracted from the former, without any special prep- 
aration. But the unfortunate inoculation of a communicable dis- 
ease in some instances of transplantation brought the operation 
into disfavor. With the advance in pathological knowledge, more 
especially that of bacteriology, better methods for its performance 
have been devised. 

Replantation is called for in instances in which teeth have 
heen forced from their investment by accident, or extracted by 
mistake, or taken out in special conditions. There is no bone 
that heals so readily as does the alveolar process of the 
maxilla, and even though there are compound fractures the parts 
readily unite if nutrition can be kept up in them. A tooth may be 
knocked out by accident, and may even remain out for a consider- 
able number of hours, and if it is simply washed off and placed 
back in the socket it may readily unite again. But if no antiseptic 
precautions are taken the probabilities are that an alveolar abscess 
will be the consequence. 

It is sometimes good practice to extract a tooth with the expec- 
tation of replacing it. A broach may have been forced through 
the foraminal opening, which it has been found impossible to re- 
move. In a number of such instances that have presented them- 
selves to the author, he has promptly extracted, removed the 
broach, given proper treatment, and reinserted the tooth, always, 
so far as he knows, with success. Cases of persistent and un- 
accountable pain that was located in the tooth have been so 
remedied. In instances of incurable alveolar abscess, perhaps due 
to secondarily infected pockets, or to foci of infection along the 



REPLANTATION, TRANSPLANTATION, IMPLANTATION. 



239 



side of the root where there were nutritive canals penetrating to 
the pulp through the dentine, or in which the inflammation was of 
that low, indolent, subacute nature in which neither resolution nor 
active suppuration could by any usual means be brought about, 
the author has frequently extracted the tooth, and after proper 
treatment and preparation replaced it. Sometimes the mere trau- 

Fig. 79. 




Penetration of Coccus Forms into the Tubules of a Replanted Tooth, showing 
that the Process of Decay does not Materially Differ from Ordinary Caries. 
(Miller. Compare with Fig. 19.) 

matism of the extraction was sufficient to induce an active, acute 
inflammatory stage, in place of the sluggish one. The possible 
contingencies are such, however, that this method of treatment 
is only recommended as a last resort when all other means of 
relief shall have failed. 

In all cases of plantation the most careful antiseptic measures 
must be employed. When the tooth is extracted, or as soon as 



240 



ORAL PATHOLOGY AND PRACTICE. 



possible after its violent removal by accident, it should be placed 
in a warm bichloride of mercury solution for sterilization. It 
should be handled with a clean napkin, and in any subsequent 
manipulation should be frequently returned to the sterilizing 
solution, which may be kept warm by placing the vessel containing 
it in a larger one holding warm water. The pulp chamber should 
be drilled open, and its contents, with those of the root canals, care- 
fully removed. After sterilization and drying they should be 
thoroughly rilled, any openings, foraminal or through the body of 

Fig. 80. 




Invasion of Rod and Thread Forms in Replanted Tooth. 
At a is shown the well-known "pipe-stem" appearance. (Miller.) 

the root, being especially looked to. The apex must be made 
smooth, and if the tooth ends in a sharp point it is well to cut this 
off, carefully polishing the exposed extremity. If the perice- 
mentum which comes away with the tooth appears red and con- 
gested, it should be removed without any injury to the tooth itself. 
Placing the prepared tooth in the sterilizing solution, atten- 
tion should now be directed to the socket. This must be 
thoroughly washed out by syringing with an antiseptic solution, 
either of the mercuric chlorid I : 2000, or some other effective 
one. If pus is present, a disinfectant like peroxide of hydrogen or 



REPLANTATION, TRANSPLANTATION, IMPLANTATION. 24I 

pyrozone should first be used. All these should be employed at 
blood temperature, or about ioo° F. If there is any specially 
septic condition the alveolar socket should be minutely examined 
with a probe, to determine the existence of secondary pockets,, 
which should be thoroughly sterilized. 

If it is a case of transplantation, the tooth should now be tried 
in the socket, when if necessary the latter may be deepened or 
enlarged. No fear of any specially threatening consequences need 
be entertained, because the formation of new bone is probable and 
desirable. 

When everything is ready' the tooth should be taken from the 
sterilizing solution, and quickly and firmly carried to place. A 
little subsequent pain is to be expected, because of the presence of 
fluids in the socket; these will be gradually absorbed into the 
tissues. Care must be taken that the tooth shall not, for a few 
days, occlude with any antagonist, and thus keep up an irritation. 
It must be held firmly immovable by some specially devised 
apparatus, or by the use of a ligature woven about the planted tooth 
and a few of the adjoining teeth. 

It is surprising how well the ligature, when skillfully adjusted, 
will hold a tooth. No surgeon would attempt to reduce a fracture 
and then neglect the adjustment of a splint to hold everything 
immovable. The ligature is frequently the best splint that can be 
employed for loose teeth. Kowarski's paste, made of powdered 
celluloid and acetone, will hold the ligatures in position and form; 
a very efficient and lasting aid in the work. 

The only subsequent treatment necessary will usually be to see 
that all remains aseptic. If necessary, careful irrigation with a 
sterilizing solution should be kept up until new tissue has begum 
to form. If there is the least sign of infection, or of breaking 
down, it is usually better to remove the tooth, search for any 
irritants, more carefully sterilize, and insert it again. 

Implantation has become an accepted method of practice with 
many oral surgeons. It had been successfully performed, but public 
attention was never specially called to it until Dr. W. J. Younger 
repeatedly demonstrated its entire practicability. The opera- 
tion consists in the forming of an artificial socket in the 
alveolar process, and the insertion into it of a tooth previously 
extracted. Nor is it essential, although it is advisable, that the 

17 



242 



ORAL PATHOLOGY AND PRACTICE. 



implanted tooth shall have been recently extracted. Successful 
operations have been made with teeth that have been lying about 
the office for years. A very superficial comprehension of the con- 
ditions involved will, however, convince any one that such an 
operation will give very much less promise of permanence than 
when a tooth not full of cracks and checks is selected. It does 
not need much physiological or pathological knowledge to demon- 

Fig. 81. 








longitudinal section of decayed dentine from a replanted tooth, showing the 

Distended Tubules. 



a, Liquefaction caverns, 
tine. (Miller.) 



b, Rents due to the advanced stage of decomposition of the den- 



strate that, other things being equal, the better and fresher the 
tooth to be implanted the greater the chances for lasting success. 

The first thing, when implantation is contemplated, is the 
selection of a tooth. This should be done with an eye to tempera- 
ment, size, and form. The proportion of the length and thickness 
of the root to the depth and breadth of the alveolar process should 
be observed, so that proper adjustment may be possible. The 
directions given for the proper preparation of a tooth for replanta- 
tion are applicable to cases of implantation, and need not be 
repeated. 

The formation of the artificial socket in the alveolar process 
is done by laying back the gum and periosteum from the selected 









REPLANTATION, TRANSPLANTATION, IMPLANTATION. 243 



place, through the means of a crucial incision. Then with the 
proper instruments the socket is cut to a sufficient depth and 
enlarged as is necessary, the previously prepared tooth being 
occasionally lifted from the sterilizing solution in which it should 
be kept, and tried in to determine the direction, as well as the 
depth and size of the hole, which should not be so large as to 
permit the root to be loose. Finally, the tooth is inserted, and a 
proper splint or ligature used to hold it immovable. If it does not 
readily and quickly become attached and within three or four 
days appear comparatively firm, it is better to remove it, freshen 
the walls of the socket with the bur, sterilize it again and replant 
it; or, what is better, obtain another tooth and insert that after 
its proper preparation. 

The operation is really but a simple one, as there are not likely 
to be any complications, unless in very rare cases tetanus might be 
induced. Should there be any indications of this, ten to fifteen 
drops of belladonna may be administered every four hours. Care 
should be exercised about drilling too deeply and thus severing 
arteries or nerves that might be avoided. No one should attempt 
the operation unless he is thoroughly familiar with the anatomy 
of the parts, for it is possible to do serious injury. 

The point of greatest interest lies in the possibility of perma- 
nent attachment and the character of the changes that are involved. 
It does not seem possible that there can be any revivi- 
fication of tissues that perhaps have long been dead. As 
for the enamel, the proportion of living matter it contains 
is too small to be taken into account. The dentine is in 
precisely the same state as in other devitalized teeth in which the 
root canal has been successfully filled. It is not at all in relation 
with any of the other tissues of the body, being completely 
enveloped and segregated by the overlying enamel and cementum. 
The latter tissue, and the pericementum, are the only ones to be 
considered, and a little examination into their probable state may 
be profitable. 

The studies of implanted or replanted teeth made after they 
have been subsequently lost reveal no conditions that may not 
exist in those remaining in their natural sockets. They may be 
attacked by caries which will not materially differ from that of 
ordinary devitalized teeth. Into the tubules of their dentine 



244 



ORAL PATHOLOGY AND PRACTICE. 



organisms may penetrate, as in other instances of tooth infection. 
(See Fig. 79.) There may be melting down of the intertubular 
substance, distention of the tubtdi. -and destruction of the dentine 
as in the usual forms of caries. (See Fig. 80.) The same minute 
caverns and liquefaction foci are formed, with the fracturing and 
breaking up of the weakened tissue, that may be observed in 
teeth that have never been extracted. (See Fig. 81.) When 
they are lost through resorption of the cementum and dentine 
of the root, the appearances indicate that it is a process identical 
with that by which the roots of deciduous teeth are removed — the 
action of the osteoclasts or resorption cells that are formed. (See 
Figs. 82 and 83.) 

Fig. 83. 



Fig. 82. 





Resorption of the Roots of Deciduous „ T 

„ TT _ Resorption of Implanted Tooth, show- 

Teeth as Lsually Observed. 

inc. Labial and Lingual Aspects. 

In the latter the projecting central portion 

is the gutta-percha root rilling. (Practice of 

Dr. William Jarvie.) 

In all cases of plantation of teeth the final success of the 
operation must depend either upon the reunion of sundered tissues 
tfr the growing of new. Osteoblasts may exist anywhere in the 
substarrvr^e of the bone, or may be developed at any point where 
the artificial socket is made. Some of them must neces- 
sarily be encountered, and they will serve as the initial points for 
the growth of n^w bone. A new periosteum (or in this case 
pericementum) must be developed to form the nutritive organ of 
the new tissue. The inflammation developed by the trauma results 
in the effusion of the lymph necessary for these new growths, and 
thus the cavities in the bone are filled with granulations as the 
consequence of the development of a new pericemental membrane. 
Without the growth of ne w pericementum it is difficult to imagine 
either the formation of ne w tissue or the nutrition of that already 



REPLANTATION, TRANSPLANTATION, IMPLANTATION. 245 

in existence. Under favoring conditions this is as readily organ- 
ized as any other tissue, and it would appear that its formation must 
be the initial step in all these conditions. 

Thus we can readily account for the reconstruction of perice- 
mentum and bone. The cementum of the tooth structure is 
already formed. No instances of any further growths to it in 
these cases have been brought to professional notice. If any such 
do exist they must appear as hypertrophies, brought about 
through the formation of cementoblast cells and their physiological 
activity, a process that does not seem probable. Osteoblasts may 
be found, for there is living bone, but there is no vivified 
cementum. 

It does not appear probable that the attachment of an im- 
planted tooth can be by anything like ankylosis, as has been some- 
times urged. Only homologous tissues will unite, and bone and 
cementum are too widely differentiated ever to grow together. 
Any such kind of ankylosis, then, must imply the formation of some 
agglutinating substance which partakes of the structure of both 
tissues, and which might become continuous with the bone on 
cne side and unite with the cementum on the other. But we 
know of no such kind of hybrid or mongrel tissue, nor has any 
case of such union been demonstrated. It is true that fractured 
bones are joined by the deposition of "provisional callus," but 
that is formed, unlike osseous tissues which have a membranous 
genetic origin, through the calcification of a cartilaginous matrix, 
while this organization of new tissue must be under the domination 
of the pericemental membrane. 

If there could be formed any ankylosing tissue, it could be 
but temporary, because without a pericementum there would be 
no means by which it could be sufficiently nourished, and it must 
shortly break down. But it is as true that pericementum may be 
secondarily formed after its destruction as that any other tissue 
may be grown after its partial loss. While it is a fact that no new 
cementum is added to the tooth, nor can the cementum corpuscles 
be revivified, yet cavities in the investing bone may be filled through 
the action of osteoblasts, and these would imply the formation of a 
new periosteum or pericementum, without which necrosis would be 
the probable result. All the circumstances attending the attach- 
ment of an implanted tooth, and those of its loss after such fixation, 






246 ORAL PATHOLOGY AND PRACTICE. 

seem unmistakably to point to the formation of a new pericementum 
and the penetration of the cementum of the implanted tooth by the 
fibers of Sharpey, or their analogues, as in teeth of natural growth. 
What, then, is the probable condition of the cementum of an 
implanted tooth that had for a long time been extracted? Such 
examinations as it has been possible to make in the implanted 
teeth that have been lost and then have fallen under observation, 
have indicated resorption rather than growth. It does not appear 
that the cementum lacunae have ever been refilled with living matter,. 
but that the extent of revivification has been the penetration of the 
cementum by the transverse fibers of the pericementum, which 
thus holds the tooth firmly in place, for a time at least, and pre- 
serves it from retrogressive changes. Under these circumstances 
that which might naturally be expected too often takes place, and 
any unusual irritation, or perhaps some nutritional derangement, 
results in the formation of osteoclasts, with the resorption of the 
cementum. This is the usual process by which an implanted tooth 
is lost. There being no formation of living matter within the 
cementum cells, but simply the penetration of the pericemental 
fibers, the tooth only remains in a state of tolerance. The usual 
period of retention, when the work is skillfully done,- is sufficient, 
however, to justify the operation, when no special service is 
demanded aside from the preservation of appearances. 



CHAPTER LIII. 

SYPHILIS: GENERAL CONSIDERATIONS. 

The introduction of the study of diseases like Syphilis in a 
book of this character may, by the advocates of a restricted dental 
practice, be thought quite outside its scope. Were it a strictly 
venereal disorder this would be quite true. But when we reflect 
that some of the gravest manifestations of syphilis are in the oral 
cavity, and remember that many of them are highly infectious, 
and that the danger to the dentist himself as well as to succeeding 
innocent patients is extreme unless intelligent precautions are 
taken, the absolute necessity for a comprehension of the nature of 
the symptoms manifested becomes at once apparent. The average 



SYPHILIS I GENERAL CONSIDERATIONS. 



247 



dentist has heard and read of the fearful consequences that may 
be the result of operations for syphilitic patients, but he has not 

Fig. 84. 




Chancre in the Palm. 
The subject is a dentist who gives a unique history. He injured his hand a month pre- 
vious to the appearance of the chancre, while filling a tooth with gold. A plugger held in 
the unaffected hand suddenly slipped, causing a slight abrasion. This healed in a few days, 
but subsequently developed into the condition shown in the photograph. The lesion was 
about the size of a hazelnut, well raised, with a surrounding area of induration, covered in part 
with pale granulations. The axillary glands and those at the elbow were enlarged. Later 
on a roseola appeared in the trunk. (Dr. Grover W. Wende.j 



the knowledge that would enable him to recognize a case when 
presented, or to distinguish between such exhibitions of its viru- 



248 ORAL PATHOLOGY AND PRACTICE. 

lence as are dangerous and those which are entirely harmless 
and non-infective. He looks with suspicion upon any sore in 
the mouth, and shrinks from a simple aphthous spot as involun- 
tarily as he would from a pernicious mucous plaque. 

On the other hand, his ignorance may permit him to exhibit 
the most reprehensible recklessness, and not recognizing upon a 
poisoned instrument that which is deadly in its nature, carry in- 
fection to some innocent child, and inoculate it for that which 
shall blast its whole future life. Dr. G. W. Wende, of Buffalo, 
has in his large collection of photographs of cases of syphilitic 
infection representations of some most pitiable instances of the 
inoculation of dentists and surgeons when operating (see Fig. 84), 
•of chancres produced in children through kissing, of others upon 
the faces of patients through the prick of a dentist's excavatcr, 
infections by means of drinking glasses and through other un- 
usual and unsuspected channels. The importance to the dentist, 
then, of a careful study, especially of the oral manifestations of 
syphilitic infection, cannot well be over-estimated. Nor can he 
comprehend the significance of these without some knowledge 
of the character and progress of the disorder. Hence the inclu- 
sion of some instruction in syphilitic degenerations should form 
■ a part of the curriculum of dental study. 

The introduction of the minutest amount of the discharge from 
a syphilitic sore, in certain stages of the disease, will inevitably 
produce the chancre which is the initial lesion. Nothing short of 
•complete asepticism will prevent this, nor will any subsequent 
sterilization neutralize the poison when once it has gained en- 
trance. Anything, no matter what, which will carry this deadly 
virus, may be the cause of inoculation. It may not even be 
essential to pierce the epidermis. Any accidental sore, or fissure, 
or abrasion, may afford entrance to the specific organism, and 
hence there is no absolute safety from infection from a syphilitic 
sore, save by the most rigid sterilization of everything brought 
in contact with it, or with fluids or matter infected by it. And 
yet, surgeons and dentists are constantly operating for syphilitic 
patients without being inoculated. There is really no great danger 
to the operator provided he observes proper precautions. The 
author has frequently worked for patients with infective plaques 
111 the mouth, without apprehension. He always, however, uses 



SYPHILIS I GENERAL CONSIDERATIONS. 249 

a set of instruments that are never employed for other patients, 
and he will not subject those like the dental engine to the risk 
of infection. After such operations, napkins, rubber dam, etc., 
are burned, while everything else used is subjected to careful 
sterilization. 

There are certain stages in which syphilitic discharges are 
quite non-infective. There are others in which the danger, while 
possible, is very remote, and yet others in which the slightest 
inoculation is positive and certain. And not only may the discharge 
from the syphilitic sore be infective, but the very blood of the 
syphilitic patient may be poisonous, and a single drop of it may 
produce a true chancre. The secretion from a mucous plaqu? 
may be mixed with the saliva and that be made the medium of 
infection. Hence, in the infectious stages of acquired syphilis, 
prophylaxis is of far greater importance in the mouth than in any 
other anatomical region. In inherited tertiary syphilis there may 
exist the most repulsive and apparently threatening sores, yet 
they are wholly non-infectious. In the acquired tertiary form, 
while there may exist the possibility of infection, the danger is 
very slight. Some of the lesions of the secondary stage are as in- 
fectious as the primary sore, but the ordinary eruptions are harm- 
less. The initial lesion of primary syphilis, the true chancre, no 
matter what may be its location, is always deadly and its dis- 
charge inevitably infective. Such apparently contradictory condi- 
tions demand technical knowledge of the disease if the practi- 
tioner is to know when and how to operate with safety to himself 
and to others. 

The oral lesions that are dangerous, aside from the primary 
chancre, which may appear upon the lip or in the mouth, belong 
to the secondary, the eruptive stage, and consist of the degenera- 
tions of mucous membrane that are analogous to those taking place 
in the skin. They do not essentially differ from the eruptions on 
other parts of the body, but are merely modified by the conditions 
existing in the tissues in which they appear. Mucous membrane 
is the covering of the internal parts of the body, as the skin is of 
those which are external. Each is continuous with the other, has 
nearly the same structure, and has like functions. Both are 
covered with epithelial scales, which are continually exfoliated 
and as constantly renewed. But in place of the sebaceous and 



25O ORAL PATHOLOGY AND PRACTICE. 

perspiratory glands of the skin, the mucous membrane has mu- 
cous follicles, whose secretion keeps it in a moist condition. 

An eruption due to an identical cause may present a far differ- 
ent appearance on mucous membrane from that exhibited upon the 
external cuticle. In the mouth, where the secretion of the salivary 
glands is added to that from the mucous follicles, this variation 
is very much intensified, and an eruption which upon the skin 
might present the appearance of nothing more than maculated 
spots may here exist as erosions. Another, which in the same 
stage upon the skin would present the form of a simple papule, 
in the mouth is macerated and softened and irritated until the 
papules break down and appear as mucous plaques. This must 
be needfully kept in mind by the student, who should not forget 
that the existence of a cutaneous eruption will be likely to appear 
in the oral cavity as mucous plaques and eroded patches. The 
presence of the former should always prompt the practitioner to 
look in the mouth for the latter. It is impossible in a work like 
this to afford anything like an exhaustive study of the subject, 
but the author will endeavor to summarize the most salient points, 
before proceeding to which he has thought it necessary to present 
these general remarks. 



CHAPTER LIV. 

SYPHILIS: THE PRIMARY STAGE. 

Syphilis is a constitutional, infectious disease, which may be 
acquired by direct contact or transmitted by a tainted parent to the 
child, and so received by inheritance. The virus is exceedingly 
virulent in character, and in time affects every tissue of the body, 
even to the hair and nails. It is believed to be due to a specific 
organism, though none has been positively identified. As has 
been already said, while usually a venereal disease acquired by 
sexual congress, it may be communicated to any abraded surface 
by any agent that will convey the virus. The primary sore may 
be upon the lips of the person affected, and he or she may com- 
municate it by kissing, or it may be carried by surgeons' or den- 
tists' instruments, or even by drinking vessels. 

While the most malignant of diseases, there is none which so 



syphilis: the primary stage. 251 

directly and unmistakably yields to properly directed medication. 

It is the belief of many physicians that drugs have no curative 
power, but that all recovery from diseased conditions is due to 
functional activities, and that medicines can do no more than to 
fortify nature to support vitality, to invigorate function. The 
fact that syphilis is positively curable by medication, that it is 
indisputably amenable to specific agents, is the insuperable ob- 
stacle to the acceptance of the dogma that drugs have no imme- 
diate remedial action, but that all cures are through the vis inedi- 
catrix nature? — the recuperative or healing force inherent in func- 
tion. 

It is only when acquired by inoculation that syphilis presents 
all its characteristic phenomena. When it is congenital, i.e., 
inherited from syphilitic parents, it does not pass through all the 
incubative stages, and is without the initial lesion or sore. Our 
attention therefore will primarily be directed to acquired syphilis. 

The primary sore which is produced by inoculation with the 
syphilitic virus is called the Chancre. It is located at the point of 
infection, and is single. (See Fig. 84.) It does not make its 
appearance immediately after infection, buc there is a period which 
varies in length from ten to sixty days, during which the specific 
virus is insensibly working', before an unmistakable lesion is seen. 
This is called "the period of first incubation." 

The chancre, or primary sore, presents certain characteristics 
which, while not affording an infallible criterion in diagnosis as to 
its nature, yet when linked with the whole clinical history should 
prevent any egregious errors. But it should not at once be sus- 
pected that every sore in the mouth, upon the lips, or even the 
genitals, is of syphilitic origin, without confirmatory testimony. 
Many an innocent person has rested under suspicion because of the 
appearance of a papule, vesicle, or pustule upon some portion of the 
body. Dentists should be especially careful in their deductions, 
and should not precipitately pronounce a lesion "specific" until it 
is unmistakably proved such. 

It is a very delicate matter for a practitioner to whom applica- 
tion for professional services is made by a respectable person, 
in whose mouth or upon whose lips there exists a suspicious sore, 
to ask any pointed questions as to its origin. And yet it is of the 
utmost importance, not only to the dentist personally, but to his 



252 ORAL PATHOLOGY AND PRACTICE. 

•other patients, that he should know the truth. He cannot com- 
mence any special inquiries until he has something definite upon 
which to found them, for an innocent person is likely to consider it 
a mortal offense if he or she is suspected of infection with so loath- 
some a disorder. Fortunately, it is not usual for lesions to make 
their appearance in or about the mouth until the existence of the 
disease is well known to the patient, and before that time arrives 
he or she has probably been under the care of a physician. Know- 
ing the exigencies of the case, they will then in most instances be 
ready to respond at once to guarded inquiries. But it should be 
comprehended that these remarks do not apply when the chancre 
originally appears about the mouth. It is only when the oral 
indications are secondary that the patient himself will comprehend 
their character and significance. 

The first prerequisite to the identification of a syphilitic sore 
will be found in the history of the case. If it appears upon the 
genitals, there must have been an exposure through an impure 
connection. It is needless to say that while the physician patiently 
listens, without expressing any dissent, to tales of water-closet 
infection, he will in his mind give them just the weight to which 
they are entitled. If the primary sore appears about the mouth 
there must have been a history of infection in some way, and that 
may be even less creditable than when the inoculation is through 
natural sexual intercourse. On the other hand, it may be by 
entirely innocent means. It may tax the ingenuity of the practi- 
tioner to discover some way in which to determine this point. 

The chancre, which is positively indicative of syphilitic poison- 
ing, presents these three distinguishing features : 

a. An incubative period preceding its appearance. 

b. Certain special characteristic appearances. 

c. Glandular enlargements and indurations. 

The period of incubation, as has already been stated, is an 
average of about twenty-one days. But it should not be under- 
stood that symptoms of infection will always manifest themselves 
after exposure. Some people seem to have almost an entire immu- 
nity to ordinary inoculation, and may escape when another would 
not. There are conditions of the system in which one is more 
liable to infection than in others, as is the case with other commu- 
nicable disorders, so that a person may possibly pass through the 



SYPHILIS : THE PRIMARY STAGE. 



253 



fire more than once without being burned. Very old and very 
young persons are especially liable to infection, because of their 
weak resisting' powefs; arid the same may be said in anemia,, 
malaria, alcoholism, and other atonic conditions. 

The first appearance of the chancre is usually as some kind of a. 
papilla or pimple situated at the point of infection and varying in 




Chancre on the Upper Lip. Commencing to Ulcerate. (Wende.) 

size. It may never be large enough to attract special attention, 
but usually it continues to increase until it is as large as a dime. 
It is dark in color, elevated very little above the general surface,, 
and is imbedded in an indurated, subcutaneous, infiltrated mass,, 
which between the thumb and finger feels like cartilage. This 
hard base, with the entire absence of pain, burning, itching or 
fever, and with the glandular affection which is soon manifest, 



354 ORAL PATHOLOGY AND PRACTICE. 

may be considered pathognomonic of the syphilitic infection. 
After about ten days the epithelia upon the surface of the chancre 
softens and it becomes covered with a gray film. Then the central 
point ulcerates and discharges a serum which is highly infectious. 
(See Fig. 85.) 

Very soon after the appearance of the chancre the nearest 
lymphatic glands become enlarged and indurated, thus indicating 
the beginning of the constitutional affection. If the primary in- 
oculation is venereal, the inguinal glands will be the ones first 
attacked, and form what is called the indolent bubo. A gland 
may even break down and suppurate, and cause an ulcerative 
bubo. If the initial point of lesion is about the mouth, the sub- 
maxillary salivary gland is affected, and may be felt as a swollen 
hard lump beneath the jaw. A little later the cervical lymphatics 
l>ecome engaged, and may be felt, or even seen, presenting their 
characteristic appearance. In suspected chancre of the lip the 
condition of the sub-maxillary gland will be a great help in mak- 
ing a diagnosis. 

The chancre is single. The instances in which two or more 
appear are very rare. It is not auto-inoculable, and in this respect 
materially differs from chancroid, or false chancre. It usually heals 
readily, without any scar or deep mark, and that without special 
local treatment. The time of its duration is somewhat uncertain, 
and depends upon the type which the disease assumes. Very 
young and very old persons are likely to be more violently at- 
tacked, and the chancre may in these instances persist longer. 
The same may be said of atonic and anemic individuals, or those 
suffering from tuberculosis, malaria, or alcoholism. In these cases 
the whole affection is likely to assume a malignant type, and the 
sore may continue until the appearance of the secondary symptoms. 

In the primary stages mercury seems almost a specific, and if 
the system will bear it in sufficient quantities the progress of the 
infection is stayed. Sometimes, however, this remedy produces 
such derangements that it is impossible to continue its free use, 
and the doses must be reduced. Ptyalism with intense glossitis 
may supervene, and other general disturbances may be of such a 
grave character that it will be found imprudent to push it suffi- 
ciently to neutralize the virus completely. The chancre should 
be treated antiseptically, and if necessary cauterized to hasten the 
healing. 



THE SECONDARY STAGE OF SYPHILIS. 255 

CHAPTER LV. 

THE SECONDARY STAGE OF SYPHILIS. 

With the disappearance of the primary sore commences the 
second period of incubation, or that in which the virus is insid- 
iously but steadily invading all the tissues of the body. This 

period, like the first, is variable, and may extend from three weeks 
to six months, or even more, seven weeks being about the aver- 
age. At the end of that time there commences a train of symp- 
toms which denote that the infection has passed beyond the 
local stage, and through the lymph channels has reached every 
organ and tissue of the body. During this second period of 
incubation the uninformed victim might imagine the disease 
cured, but that is by no means the case. The virus is very active, 
though without any outward manifestations, until it exhibits its 
destructive energy in constitutional symptoms. 

The indication of the completion of the second period of incu- 
bation and the commencement of the second stage of syphilis is the 
appearance of the so-called syphilides, or syphilodermata. These 
are the eruptions of various kinds which appear upon different 
parts of the body. The first of these is most commonly a kind 
of roseola, or redness of the skin, which covers the thorax, occa- 
sionally the abdomen, and sometimes nearly the whole body, 
very rarely appearing on the face. It is symmetrical, occurring 
on both sides of the median line alike, and not coming as irregular 
desultory blotches. Like the chancre, which marks the primary 
stage, this eruption is without any functional disturbance, and 
in this absence of burning or itching or fever differs from all other 
skin eruptions. The roseola is entirely superficial and spontane- 
ously disappears after a variable period, to be succeeded by other 
forms of eruption. 

The syphilides of the secondary stage appear on both the 
skin and the mucous membrane, and may be erythematous (red 
blotches), macular (pigmented spots), squamous (scaly), vesicular 
(sac-like), pustular (pimples), tubercular (nodules), rupial 
(crusts), or they may assume any intermediate form. The syphilitic 
sore throat, which usually accompanies any of these forms, is 
really the eruption upon the mucous membrane of the pharynx. 



256 



ORAL PATHOLOGY AND PRACTICE. 



The mucous plaques, or mucous patches of the mouth, are the 
same eruptions, changed in their appearance by the character of 
the tissue in which they are manifested, and by their environ- 
ments or surroundings. 

For the purposes demanded by the present study all the syphil- 
ides may be divided into three classes — the macular, the papular, 

Fig. 86. 




Mucous Plaque or Patch (Papulo-erosivk Plaquk) upon the Tongue. (Wende.i 

and the pustular. The first when they appear upon external cuta- 
neous surfaces are primarily only pigmented spots, like freckles, 
not raised above the surrounding tissues, tending to circular 
groupings, and of a coppery color. They may entirely disappear 
and be succeeded by, or they may assume, the papillary form, and 
spread. They appear innocent and give the patient no incon- 
venience. 



THE SECONDARY STAGE OF SYPHILIS. 257 

In the mouth and upon mucous membrane the eruption is 
usually first seen in this macular form, — that is, of reddish or copper 
colored spots, not raised above contiguous surfaces. They may be 
observed over the arch of the soft palate, upon the tongue and 
pillars of the fauces, on the buccal surfaces, and along the mucous 
membrane where it doubles upon itself and where it is hidden from 
ordinary observation. Especially are they apt to appear beneath 
the tongue and upon the folds of the membrane in that locality. 
They may be the size of the finger nail or they may be mere 
punctate spots. Usually they very soon disappear and are suc- 
ceeded by the papules. 

The papular form is that which succeeds the macular. It con- 
sists of reddish pimples appearing upon the skin, which from a 
single point spread, or from a number such become confluent. 
Gradually these papules become more pronounced and separate, 
certain of them perhaps degenerating and assuming an aggra- 
vated appearance, while between them the others disappear or 
become scaly, the surface being exfoliated, and so the eruption 
takes upon itself the third or pustular form. This is the most 
common manner of progression, but in some malignant instances 
the macular seems very quickly to degenerate into the pustules, 
without the appearance of papules. 

In the mouth the papular form assumes different characteris- 
tics. Instead of gradually becoming pustular, the surfaces are 
macerated in the oral fluids and soon appear as erosions. There is an 
infiltration into the sub-mucous tissue, and this causes a raising 
of the edges, while the sore is imbedded in a stroma of the thick- 
ened, slightly sclerotic base. The center softens and is covered 
with a grayish film, which discharges a sanious, highly infective 
fluid. This sore will have sharply defined edges, a dark red 
aureola surrounding it, an excavated surface and a crater-like 
general aspect, with necrotic tissue on or in it, when seen in its 
worst phases. In less pronounced cases it may be only a round 
or ovoid sore of a yellowish color, no aureola, with but a slight 
excavation and a discharge which is not as profuse, but is quite 
as infectious as is the other. 

The appearances described in the preceding paragraph form 
what are called the "mucous plaques" or "mucous patches" of sec- 
ondary syphilis. (See Fig. 86.) They are the oral syphilides 

18 



258 ORAL PATHOLOGY AND PRACTICE. 

which the dentist should most carefully guard against. They 
will most frequently be observed on the borders of the tongue, 
but may be found anywhere on the oral mucous membrane, the 
uvula, in the pharynx, and where two surfaces come in contact. 
They may degenerate into deep ulcers and be accompanied with 
acute glossitis, or swelling of the tongue, which may thus press 
against the teeth and its edges and be made to assume an indented 
or scalloped appearance. These phenomena disappear sponta- 
neously in time, sometimes leaving deep furrows as the result 
of the glossitis which may be present. 

The pustular form of the eruptions upon the skin may be 
degenerations of the papules, or the latter may disappear entirely 
to be succeeded by the pustules. Gradually the papules may become 
more pronounced and some of them may take on the pustular 
form, softening at the center and discharging a sanious fluid 
which is exceedingly infective. These may become aggravated 
and ulcerate and be very offensive. If, on the other hand, the 
disease does not assume a malignant type, they may dry up and 
disappear without ulceration. They may appear on the scalp or 
lower extremities as cone-like elevations, giving rise to large, 
irregularly shaped ulcers, secreting a bloody pus that dries up 
and forms dark brown or black crusts, or they may dry down and 
exfoliate the surface in the shape of scales, thus forming the 
squamous syphilides that may possibly be mistaken for psoriasis, 
or itch. It may thus be seen that the eruptions of secondary 
syphilis very widely differ in appearance, depending upon the 
constitutional condition of the patient and the type of the disease. 
This pustular form does not offer the same phenomena in the 
oral cavity. On mucous membrane the mucous plaques may ulcerate 
and cause considerable pits, but they do not rise into cone-like eleva- 
tions. As already asserted, there is no essential difference in the 
conditions, the mucous plaques or patches being the analogues 
of the papular eruptions upon the skin, and their ulceration an- 
swering to the pustules which appear on external cutaneous sur- 
faces. When the one is present the other may be looked for in 
its proper place, the difference in manifestation being due to the 
modifications of the tissue. 

During all this time the enlargement and induration of the 
lymph glands has been increasing and extending. They may proba- 



TERTIARY AND HEREDITARY SYPHILIS. 259 

blv be felt at this time along the posterior border of the sterno- 
cleido-mastoid muscle, the other cervical glandular regions, and 
those of the supraclavicular and epitrochlear localities. They 
vary in size from that of a pea to a pigeon's tgg, are round, hard, 
and painless. 

At the same time the constitutional disturbance begins to 
manifest itself in fever, the bodily temperature rising perhaps to 
102° F., in pains of neuralgic or rheumatic character, and in severe 
headaches. There will be restlessness and sleeplessness, all the 
symptoms being worse at night, and exacerbated by fatigue or by 
exposure to extremes of temperature, by wet feet or any unusual 
exposure. The virus is infecting the deeper organs and interfer- 
ing with functional activity. 

It should always be borne in mind that the characteristic secre- 
tions of the syphilodermata are infectious in the highest degree. 
The blood at this time, as has already been intimated, may con- 
tain the virus to such an extent that it becomes noxious, and 
inoculation with it may produce the true phagedenic chancre. 
The saliva may be mixed with the discharges from mucous 
plaques and also be capable of communicating the disease. The 
whole system, in fact, is a loathsome, pestilential mass of corrup- 
tion, revolting to the sufferer himself and abhorrent to others. 



CHAPTER LVI. 
TERTIARY AND HEREDITARY SYPHILIS. 

Tertiary Syphilis is the final result of the specific infection. 

It is a breaking down of the tissues under the degenerative process, 
and is characterized by a worse series of syphilides, by necrosis of 
the hard, and ulceration, sloughing, and perhaps gangrene of the 
soft tissues. It is a process of general destruction, and some of its 
forms are repulsive in the extreme. The discharges are not, 
however, of such an infectious nature, and hence it is of less interest 
to dentists than the earlier forms of syphilis, but it should not be 
imagined that they are wholly without danger. 

The period of incubation between the secondary or eruptive 
and the tertiary or constitutional stages is very uncertain. Some- 



200 



ORAL PATHOLOGY AND PRACTICE. 






times the latter succeeds almost directly upon the heels of the 
former, and in other instances years may elapse after the disap- 
pearance of the syphilides before tertiary symptoms become 
manifest. Dr. G. W. Wende, of the University of Buffalo, reports 
one case in which only four weeks elapsed between the initial 

Fig. 87. 




Gl mma upon the Dorsum of the Tongue (Gummatous Infiltration). 
(Wende.) 

sore and the appearance of tertiary symptoms. In four months 

syphilitic necrosis had eaten away nearly all the bones of the 

. destroyed the sight, and almost blotted out every feature. 

The author saw cases in the island of Cuba which assumed such 

lignant form that there were no marked stages or periods, 



TERTIARY AND HEREDITARY SYPHILIS. 



26l 



the one succeeding the other so quickly. Indeed, hospital sur- 
geons in Havana report that a typical form there is almost or quite 
incurable. 

The syphilides of the tertiary stage commence with the appear- 
ance of tubercles or gumma, the former being in the skin or mucous 



Fig. 




Toads-Back Appearance in Syphilis. 
Gummatous Infiltrations (papulo-hypertrophies) producing the so-called toad's-back 
appearance. (Wende.) 

membrane, while the latter are subcutaneous or submucoid. 

The advent of either in syphilitic patients is an indication that 
the disease has passed the eruptive or secondary period, and has 
reached the tertiary or constitutional stage. Tubercles are gran- 






262 ORAL PATHOLOGY AND PRACTICE. 

tilar nodosities, usually very small and numerous, which may be 
felt in the epidermis. The gumma are thickened, swollen masses 
in the tissues beneath the surface, and are caused by infiltrations 
into the cellular structure. (See Figs. 87 and 88.) The latter 
usually appear as circumscribed, firm nodules, varying in size from 
that of a small cherry to that of an orange. At first the skin or 
mucous membrane is uncolored, but later it is apt to change to livid 
or purple, becoming thin at the apex and finally ulcerating. The 
gumma are not ordinarily numerous, seldom exceeding three or 
four in one subject. They usually leave a deep and abiding scar. 
When they appear in the roof of the mouth, or on the turbinated 
or palate bones, they may result in necrosis, with perforation and 
destruction of those bones. 

The tubercular deposits are of special interest to the practi- 
tioner from the fact that they ordinarily prohibit surgical opera- 
tions. 

The condylomata, or venereal warts, are morbid growths, 
the result of syphilitic infection in its later stages, but as their 
observation will seldom come within the province of the dentist, 
they need not be considered here. 

There may be leucoplakia of the dorsum of the tongue, which 
is characterized by the presence of pearly or bluish white patches 
upon its surface. This is a symptom, however, upon which too 
much dependence cannot be placed, as it may be only the effect of 
excessive pipe-smoking or the wearing of an artificial denture. 

The chancroid, or soft chancre, is a sore which does not carry 
in its train any of the constitutional complications of the true Hun- 
terian chancre. It is of a pustular nature, with a secretion that is 
peculiarly infectious, but which, unlike that of the true chancre, is 
auto-inoculable; that is, it infects the person in whom it exists at 
any new point with which it comes in contact, making another 
chancroidal sore. Hence chancroids are usually multiple, while 
the chancre is single. Chancroids very rarely appear elsewhere 
than upon the genitals, and produce no oral lesions whatever. 

Hereditary or Congenital Syphilis. 

That children may inherit this dread disease from either parent 
is a well-known fact. It appears under such conditions only in its 
tertiary form. There is no chancre, and there are none of the 



TERTIARY AND HEREDITARY SYPHILIS. 263 

syphilides belonging to secondary syphilis, and hence there is no 
danger of the infection of others. The syphilitic father may 
transmit the disease without infecting the mother, and vice versa. 
If a mother acquires syphilis after her impregnation, she may 
transmit the disease to the fetus through the placental circulation. 
A healthy mother who gives birth to a child inheriting syphilis 
from the father may herself be infected, although the disease will 
be likely to assume a modified form. When there is impregnation, 
either of the parents being afflicted with recent syphilis, it is 

Fig. 89. 




Hutchinson Teeth when Recently Erupted. 

Fig. 90. 




Hutchinson Teeth Later in Life. 

usually fatal to the fetus, either before or shortly after birth. The 
longer the time between the infection and the impregnation, the 
less will be the chance of transmittance, or the milder the form 
that the disease will take, especially when the parents have been 
under treatment. 

The usual indications of inherited or congenital syphilis are 
nasal catarrh (snuffles), erythematous eruptions, especially on the 
abdomen, mucous patches, cracks at the corners of the mouth which 
refuse to heal, poor development both physically and mentally, and 
bad nourishment. Sometimes the infant is born with these indica- 
tions of its heritage, while in other instances none of them make 
their appearance for weeks, and the anxious parents are led to 
imagine that their offspring has escaped the taint, until a tell-tale 
eruption destroys their hopes. 



264 ORAL PATHOLOGY AND PRACTICE. 

Hutchinson believed that a peculiar formation of the teeth is 
indicative of congenital syphilis. This consists in a variation 
in the shape and formation of the central incisors, in which they 
are narrowed at the point and have a peculiarly crescentic incisive 
edge. (See Figs. 89 and 90.) That the so-called Hutchinsonian 
teeth are pathognomonic signs of syphilis is denied by very many, 
and they certainly' are found where there are no other indications 
of this diathesis. But most syphilologists are agreed that when 
they are accompanied by interstitial keratitis and congenital deaf- 
ness they may be considered as reliable indications. 

Fig. 91. 




Hutchinson Teeth in a Case in which there was a History of Syphilis. 



Fig. 92. 




Typical Hutchinson Teeth in which there was No Possibility 
of Inherited Taint. 

That the so-called Hutchinsonian teeth are not an infallible 
sign of inherited syphilis appears to be conclusively demonstrated 
by Dr. E. L. Keyes, in the Dental Cosmos, Periscope, Vol. 
XXVIL, page 570. A cast of the teeth of a patient then suffering 
from secondary syphilides, the primary sore having disappeared 
but a few weeks previously, shows the typical Hutchinsonian 
central incisors. Of course, inherited tertiary syphilis was in 
this instance impossible. (See Fig. 92.) 

The prognosis in inherited syphilis is much more grave than in 
the acquired form. From one-third to one-half of all syphilitic 
children die before reaching adult life. 



SYPHILIS OF THE MOUTH AND 10NGUE. 26 



The first symptoms of inherited syphilis, the early syphilides, 
usually appear within the first three months. If an infant arrives 
at the age of six months without exhibiting any of the indications 
of syphilis, it may be safely assumed that it is healthy. 

In all the later forms of syphilis almost the sole remedy upon 
which reliance is placed is iodide of potassium. Indeed, this is 
usually supposed to be a specific if administered in sufficient quanti- 
ties. There is no limit to the size of the dose, save the ability of the 
patient to bear it. Sometimes it induces functional disturbances 
of so grave a character that its use must positively be intermitted 
or the amount given reduced, and in such instances it may be 
impossible to withstand the progress of the disease. But if the 
patient can bear enough of it, and its exhibition is persisted in 
long enough, a cure is usually certain. 



CHAPTER LVII. 
SYPHILIS OF THE MOUTH AND TONGUE: RECAPITULATION. 

It was necessary to investigate the pathological changes that 
take place in syphilitic affections before its manifestations could 
be comprehended, or recognized when seen. If the nature of the 
syphilides is not learned, the dentist will not be prepared to under- 
stand their import when he meets them in practice. But it will be 
the oral phenomena that will chiefly concern him, and hence these 
should be awarded special attention, because of the possibilities of 
the transmission of the disease through his instrumentality. 

The practitioner has already been cautioned against jumping 
to the conclusion that every mucous patch in the mouth, or every 
indurated sore, has a specific origin. Any excoriation of the 
mucous surface may be greatly aggravated by special irritants that 
are common in the mouth. The chewing and smoking of tobacco, 
the holding of pipes, cigars, and cigar-holders, the drinking of 
hot and iced fluids, may intensify a local irritation until it assumes 
a very suspicious aspect. In the same manner syphilitic sores of 
the mouth may take upon themselves an irritated character or 
appearance. But it should be borne in mind that these aggrava- 
tions do not in essence differ from the same morbific changes 
occurring in other parts of the body. 



266 ORAL PATHOLOGY AND PRACTICE. 

Chancres occurring upon the tongue or in the oral cavity, 
although somewhat modified by their surroundings, present essen- 
tially the same characteristics as when they appear elsewhere. 
The same may be said of the roseola or maculae, the papules, pus- 
tules and ulcers which have already been considered. Rough or 
carious teeth may aggravate them, and modify their appearance, 
but they will not destroy their leading characteristics. As a rule, 
the syphilitic lesions of the mouth are of a moist rather than a dry 
nature, and usually assume the form of mucous patches. 

In the early stages of secondary syphilis, the eruption may 
appear in the mouth as well-defined areas of a dark red color, upon 
the soft palate, tongue, pillars of the fauces, and along the gingival 
labial borders. These may be of any size, from mere points to 
blotches covering the whole surface. But they will retain the sym- 
metrical appearance of the cutaneous eruptions, and will usually be 
seen upon both sides of the median line. Like those of the surface, 
they may disappear after proper treatment, or they may form the 
basis for further degenerations. They usually become eroded to a 
greater or less extent, this probably being due to local irritation. 

The papular syphilide of the cutaneous surface is represented 
in the mouth by mucous patches or moist papules. These may be 
single or multiple, and they are usually well defined, varying in size 
from a single point to that of a quarter dollar. They are at 
first red in color, but soon assume a whitish appearance, looking 
as if the mucous membrane had been cauterized with nitrate of 
silver. They may be raised above the general level, and are 
more or less painful. Two of them may perhaps be seen facing 
each other on membranes that are in contact, like the surfaces just 
back of the last molar tooth, or those of the cheek and beneath the 
tongue. 

The ulcerative lesions are usually the further breaking down 
of the mucous patches or gumma, and their deep erosion until they 
form considerable caverns in the tissue, which are exquisitely pain- 
ful. These may follow along the lines of the tongue, thus giving 
rise to deep fissures, or they may burrow into the crypts of the 
tonsils, or form circular pits on the posterior wall of the pharynx. 
Not only are fissures formed in the tongue, but they may make their 
appearance at the corners of the mouth or the centers of the lips. 

An acute glossitis or inflammation of the tongue is not infre- 



SYPHILIS OF THE MOUTH AND TONGUE. 26^ 

quently the result of syphilitic infection. There may be first an 
hypertrophy of the organ, with subsequent contraction, thus caus- 
ing deep transverse or longitudinal furrows. There may be an 
indurative or hardening change in the muscular fibers, with a 
consequent partial loss of function, the speech becoming thickened 
and indistinct. Along the borders of the tongue dry or squamous 
lesions sometimes may be seen. They are not moistened by the 
usual secretions of the mouth, and in color are of a grayish or 
bluish white, sometimes having a glistening appearance. These 
patches are specially marked among users of tobacco, particularly 
those who are smokers, and there is a distinct variety that has been- 
called "smoker's patches." They are not by any means confined 
to the borders of the tongue, or even io the tongue itself, but 
may appear anywhere in the oral cavity. 

Gummata of the mouth may develop during the later stages of 
syphilis. There may be a compounding of these infiltrations in 
the sub-mucous tissue of the dorsum of the tongue, causing as 
many elevations and giving the characteristic "toad's back" ap- 
pearance. (See Fig. 88.) Their initial appearance is as nodules- 
beneath the mucous membrane, from the size of a pin's head to 
that of the end of the finger, usually single, but sometimes multi- 
ple. After a time they break down into ragged ulcers, and their 
degeneration is usually rapid. Perhaps one appears in or near 
the center of the vault, and when it breaks down a probe will' 
detect necrosed bone, which is soon exfoliated, thus causing a 
perforation of the hard palate. 

The syphilides of the mouth assume a variety of forms, and 
sometimes their diagnosis is impossible, except with the aid of 
the clinical history of the syphilitic infection. They may possibly 
be mistaken for other affections. The roseola may be con- 
founded with a follicular stomatitis, and the ulcers with cancrum 
oris, or noma. Epitheliomata may be almost indistinguishable 
from some of the syphilitic lesions, though ordinarily they are much 
slower in their progress. Mercurialization may usually be distin- 
guished from syphilitic disturbances by the fetor of the breath, and 
by the distinct metallic taste. But there may be innocent ulcera- 
tions upon the tongue or oral tissues, which the inexperienced 
syphilologist might mistake if he were to depend upon their 
appearance alone. The only safe course is to group the various 



268 bRAL PATHOLOGY AND PRACTICE. 

symptoms, examine for glandular indurations, and carefully and 
delicately inquire into the history of the case when suspicious 
appearances are observed in the mouth, all the time observing 
caution to guard against possible infection, for if there happens to 
be, as is frequently the case, any abraded or wounded point in the 
fingers, it is possible for syphilitic inoculation to take pla:e from a 
secreting mouth-plaque. 



CHAPTER LVIII. 
PHYSICAL DIAGNOSIS. 



The oral physician should be competent to make a proper 
examination of a patient, for the purpose of ascertaining the ability 
to withstand an operation, to take an anesthetic, or to determine 
the probability of constitutional complications. When the regular 
physician approaches the bedside of a sick person for the 
purpose of making a diagnosis he first takes the pulse, that he may 
determine the condition of the circulation. He next looks at the 
oral tissues, especially the tongue, because upon it he will find 
reflected any disturbance of the digestive tract. When he has 
learned to read these aright he has the key to the state of the two 
most important functions of the body, upon which, more than any 
others, health depends. 

To be able correctly to interpret the utterances of the pulse, 
of the breathing, or the appearance of the oral tissues, it is essential 
that the physician know the language in which they speak. 
The technically uninstructed man may feel the pulse, but to him it 
tells nothing except that the heart is beating more or less regu- 
larly. The accomplished physical diagnostician with his eyes shut 
will at once pronounce whether the patient is strong or weak; is 
nervously excited or depressed; is in a fever or rigor; whether 
the disturbance is functional or organic; whether in the brain or 
extremities; whether there is or is not narcotic or other poison- 
ing, with many other matters that it is essential to know. 

The principal methods for determining the state of the internal 
viscera in physical diagnosis are auscultation' and percussion. 

Auscultation is the determination of the condition by listening to 



PHYSICAL DIAGNOSIS. 269 

the sounds which are produced in normal or diseased functions. It is 
called immediate when the ear is applied directly to the part, and 
mediate when a stethoscope or other instrument for conducting the 
sound is employed. 

Percussion is the striking lightly upon any part of the body, 
especially the thorax or abdomen, zvith the view of determining diseased 
conditions by the resonance or lack of resonance of the sound. It is 
called immediate when made direct with the fingers, and mediate 
when a pleximeter or some instrument is used to increase the 
sound. Usually immediate percussion is employed by laying the 
first two fingers of the left hand upon the part, and striking them 
with the ends of the first two fingers of the right hand. 

Perhaps the dentist may not need to become an expert, but 
he should at least know the most important expressions of the 
heart, the lungs, and the digestive tract, as expressed in the pulse, 
the breathing, and the oral tissues. 

The Pulse. 

The Pulse is the change in the shape and size of an artery due 
to a temporary increase in the tension of its walls following a con- 
traction of the heart. The muscular constriction of that organ 
forces the blood out of its ventricles and drives it through the 
arteries. The coats of these vessels are more or less elastic, 
according to their condition, and yield to the impulse, and if the 
finger is placed over an artery which lies near the surface a wave 
of the sanguinary fluid may be felt with each contraction as it is 
propelled from the heart forward. Of course, the nearer the 
central organ the more plainly perceptible is the impulse, while 
its character will vary with the resilience of the arterial coats. 

To be able to recognize the pulse in disease, it is necessary to 
know what it is in health. It varies in different individuals, and 
changes with their condition. It is not the same during growth as 
in maturity, and every physical state has its appropriate expres- 
sion. There is a difference of five to six beats per minute between 
the pulses of men and women of relatively the same general physi- 
cal condition otherwise. A difference of from five to ten beats is 
made by change of posture from the recumbent to the erect. By 
violent running, or any excessive exercise, the rate may be doubled. 
It is higher in infant than in adult life, and it decreases yet more 
in old age. 



2J0 ORAL PATHOLOGY AND PRACTICE. 

The pulse may be felt at any accessible artery, the larger and 
nearer the heart the more distinctly. It is usually examined at 
the point of nearest exposure of the radial artery, in the 
wrist, but dentists should be able to read the pulsation of the facial 
artery, where it crosses the inferior maxilla, because it is more 
convenient, especially in the administration of anesthetics. It may 
also be taken from the carotid artery in the neck, or the temporal 
beneath the ear. 

If the pulse is taken at the radial artery the tips of the first 
two fingers should be used, with the second finger nearest the heart. 
The strength is determined by pressing with the second finger until 
the pulse cannot be felt with the first, and taking note of the amount 
<oi force required to compress the artery. The number. of pulsa- 
tions are computed by counting. The pulse should never be taken 
when the patient is in any state of excitement, because its true 
reading cannot be obtained at that time. When first placed in the 
chair, or if a view of the instruments is obtained, the pulse may be 
raised several beats, and will be changed in its character. The best 
time will be after the patient has entered the office and sat for a 
few moments, until all nervous excitement shall have passed away. 
Then, in the midst of conversation and without intermitting it, the 
hand may be taken and the pulse examined. Of course, no alarm- 
ing display of instruments or apparatus will be permitted. 

At birth the average pulsations are from a hundred and twenty 
to one hundred and forty per minute. The rate gradually dimin- 
ishes until at seven or eight years it is about ninety. In adult life it 
is from sixty-five to seventy-five, while in old age it sinks to sixty. 
Some people have normally a very slow pulse, while others have 
one that is rapid; hence it is essential to have some knowledge of 
what is the normal rate. But an experienced physician will tell by 
its reading whether the slow or fast pulse is the result of some dis- 
turbing influence, or whether it is normal. By the use of the 
sphygmograph, an instrument devised for that purpose, he may 
obtain a permanent tracing of the pulse and all the variations in the 
blood pressure, recorded through the elasticity of the arterial coats. 
(See Figs. 93 and 94.) 

In disease the pulse presents certain modifications that depend 
upon the kind of disturbance. In the principal changes certain 
definitions are given which are definite in their meaning. For 



PHYSICAL DIAGNOSIS. 



271 



instance, there is a marked difference between a rapid, a quick, and 
a frequent pulse, and each conveys its own tale. The principal 
modifications are as follows: 

A frequent pulse means one that is diminished in force, but 
increased in frequency. It is the result of and indicates debility. 
Thus before death it may be so frequent as almost to be beyond 
counting, and so weak as to be almost indistinguishable. The 
muscle of the heart is losing its contractile force. 

Fig. 93. 




Sphygmographic Tracings of the Pulse from the Radial Artery in a Healthy 
Man, Aged Twenty-five. (Chapman.) 



Fig. 94. 




Sphygmographic Tracing of the Pulse, showing Low Tension, with Irregularity 
in a Case of Mitral Regurgitation. (Musser.) 



A quick pulse is abrupt, jerking, and may be moderate or frequent 
in its rate of pulsation. It indicates some irritable state of the heart, 
which may be of only a temporary nature. 

The slow pulse (unnaturally so) occurs in narcotic poisoning and 
in apoplexy. It will be found in compressions of the brain from 
accident, and in unconsciousness from opium or liquor. This 
characteristic enables the physician to determine malingering, and 
the simulation of unconsciousness. Another method to detect 
counterfeiting is to press the end of the thumb with considerable 
force on the supra-orbital foramen for one or two minutes, gradu- 
ally increasing it. No conscious person can long withstand this. 

The hard pulse seems to indent the finger, and is what the name 
indicates. It shows great excitement of the circulation, with high 
tension and rigidity. 



272 ORAL PATHOLOGY AND PRACTICE. 

The soft pulse is the direct opposite of this, and indicates lassitude. 
It is easily compressed, though it may not be readily extinguished. 

The febrile pulse is an increase in the rate of pulsation, and 
usually of force also. It is found in active fevers and inflamma- 
tions of an acute character. 

The feeble pulse is nearly synonymous zvith the soft pulse, but is 
more easily extinguished. It is indicative of great debility and 
exhaustion. 

The thready pulse is one that gives beneath the finger the sensation 
of a vibrating thread. It is allied to the wiry pulse, which is an 
exaggerated condition. Both are sometimes present in very great 
debility. 

The irritable pulse is one that is both frequent and hard. It will 
be found when a debilitated person is subjected to some kind of 
excitement. 

The intermittent pulse is one that now and then loses a beat. It is 
indicative of either functional or organic disease of the heart. It 
should not be confounded with the weakened pulsations of exhaus- 
tion. 

The irregular pulse is one that varies in both frequency and force. 
It may be very slight, or it may be extreme. It is generally found 
in heart disease, but it may be the result of the use of tobacco or 
strong coffee or tea. The inordinate use of stimulants may also 
produce an irregular pulse. 

In reading the pulse,- for instance to determine the ability of 
a person to withstand the effects of an anesthetic, the practitioner 
must first be sure that the patient is not laboring under the ex- 
citement of fear or apprehension. The mind should be diverted 
until the pulse is normal, when the hand may be quietly taken. 
The first thing will be to determine the frequency, to learn if 
there is any functional excitement. If so, due allowance must be 
made. Then its regularity should be observed, to discover if 
there is any organic trouble. After this its force may be ob- 
served, to ascertain if the heart is strong enough to withstand 
the shock that must be produced by the anesthetic agent or the 
contemplated operation; and finally the condition of the pulse 
should be carefully noted, to know if there is any functional irri- 
tation which would be indicated by the "quick," "febrile" or "irri- 
table" pulse. 






PHYSICAL DIAGNOSIS. 273 



The practitioner should lose no good opportunity for the study 
of the pulse, both in health and disease. He will find that his 
comprehension of it and his ability to detect variations will greatly 
increase with practice. He must learn to read it as he would 
Greek, by first conquering its alphabet, and then slowly and 
patiently acquiring the combinations. He will discover that he 
can acquire real skill and facility in reading the one about as easily 
as the other. 

It should be comprehended that all these modifications are not 
produced simply through changes in the force exerted by the heart 
in its pulsations. The readings depend upon the condition of the 
coats of the arteries quite as much. Their resilience, or elasticity, 
is governed by the vaso-motor nerves, and hence any nervous 
shock or neural depression will be readily manifested in the arterial 
walls, in the manner indicated in the section on Inflammation. 
Thus the "hard" pulse and the "soft" pulse will mainly depend 
upon the tension of the muscular arterial coats, while the "slow" 
pulse and the "frequent" pulse will be the result of the condition of 
the heart, or the rate of its pulsations. 

A "feeble" pulse indicates that the force of the heart-beats is 
lessened, and at the same time the tension and resiliency of the 
arteries themselves are reduced. The "soft" pulse, on the con- 
trary, simply implies a change in the coats of the vessels, without 
any special heart complications. 

The "hard," or "wiry," or "thready" pulse shows an undue 
tension of the arterial coats, and this will be induced through some 
nervous impression acting through the vaso-motor system. 

It may thus be seen that the pulse gives a very clear indication 
of the state of the nervous system, and reveals any neural shock or 
depression; and that at the same time it is indicative of the state of 
the blood column and of the functional activity or languor of the 
heart. 



CHAPTER LIX. 
PHYSICAL DIAGNOSIS (Continued). 

The Respiration. 
This is the inspiration and expiration of air through the 
lungs. By means of the first the blood is oxygenated, while by the 

19 






274 ORAL PATHOLOGY AND PRACTICE. 

last it is relieved of the effete products of vital action. This must 
continue as long as life lasts. The various sounds made in breath- 
ing, as well as those of the heart, may be determined by the use 
of the stethoscope, or by placing the ear to the chest, not more 
than one thickness of cloth intervening. 

The breathing is termed either abdominal or thoracic. That 
is, the muscles chiefly used may be the diaphragm, or the costal and 
superior thoracic. The breathing in man is mainly abdominal, 
while in woman it is thoracic. In forced and labored respiration 
yet other muscles may be brought into action, as the trapezius, 
serratus magnus, and the sterno-cleido-mastoid. 

In health, the respiration is from thirteen to twenty-five per 
minute. In the dyspnea of pneumonia it may rise to from thirty to 
fifty per minute. 

The normal respiration should be without effort, deep, and 
unhurried. There should be no unusual noises or rales, and the 
natural murmurs of the passage of air through the bronchial tubes 
should be present when the ear is placed to the chest. 

The amount of air respired by each individual is about five 
hundred cubic centimeters, and, of course, the same amount is 
exhaled. But it should not be understood that all the air is 
expired at any one time. After the fullest expiration there will 
still be left in the lungs fifteen to eighteen hundred cubic centi- 
meters. In forced expiration, or exhaustion, most of this air may 
be forced out. 

The purification of the blood is through the process of respira- 
tion. Oxygen is taken in, and carbon dioxid, water, and various 
organic matter are exhaled. A great deal of effete matter is 
eliminated from the pulmonary surfaces. In the administration of 
anesthetics they are usually taken into the lungs by inhaling their 
vapor, and thence pass directly into the blood; in their elimina- 
tion it is chiefly the lungs which throw them off. They circulate 
with the blood until they again reach the pulmonary surfaces, when 
they are given up. Hence, in the recovery from the anesthetic 
state, it is of the first importance that the breathing be maintained 
evenly and regularly, as otherwise the poison remains in the 
system. 

In diseased conditions the respiration may be either faster or 
slower than the normal. When it is verv much accelerated it will 



PHYSICAL DIAGNOSIS. 275 

probably be superficial, shallow, and gasping. This will be the 
case when it is above thirty-five, in pneumonia, pleurisy, obstruc- 
tions in the trachea, or any kind of dyspnea. 

It will be retarded and will be deep in narcotic poisoning and 
in cerebral compressions, falling as low as twelve to the minute. 

When the lung is filling up, becoming consolidated, it will be 
interrupted, broken, and irregular. 

Bronchial breathing will be marked by blowing, as through a 
tube, and it will have a high pitch. This will be the case in 
advanced phthisis, in exudations, hemorrhages of the lungs, etc. 

The normal sounds that are heard when the air rushes through 
the various passages are called "respiratory murmurs." In health 
these should be smooth, regular, easy, and without interruptions. 
All the involuntary muscles of respiration should work without 
effort, and the expansion and contraction of the thorax should 
be uniform and regularly periodical. The practitioner should 
carefully observe these particulars before attempting a closer 
examination, and without allowing the attention of the patient 
to be called to it', that he may learn what is the usual rate, for 
the frequency and effort may be increased by the nervous irrita- 
tion attending auscultation. 

In diseased conditions the respiratory murmurs may be ma- 
terially changed. The breathing may be labored and difficult, 
through partial closure of the respiratory passages by inflam- 
matory action, through stoppage by fluid exudations, or by nervous 
constrictions. 

The bubbling sound that is produced will be either coarse or 
fine. The coarser it is the higher up it will be, and the weaker 
will be the patient. It means the presence of water and moisture 
in excess in the air passages. These air tubes must always be 
properly lubricated, but when through some pathological condi- 
tion moisture accumulates in inordinate quantities, it impedes or 
even wholly stops the passage of the air. In the latter case the 
patient may absolutely be drowned in his own effusions. 

Gurgling, like water boiling, may be heard in pulmonary cavities 
at times, and indicates an advanced state of phthisis. 

Splashing sounds upon succussion, or shaking or striking the 
chest, in the pleural organ indicate hydro- or pyo- pneumothorax — water 
or pus, with air, in the pleural cavity. 



276 ORAL PATHOLOGY AND PRACTICE. 

Loud whistling or wheezing that may be heard at a distance in 
the larynx or trachea indicates stenosis, or constriction, and is heard 
in croup. 

Low-pitched snoring in the larger bronchi means spasms, or nar- 
rowing of the bronchi, as in asthma. 

A crackling sound located in the air vessels of the lungs shows a 
sticking of their walls, and is heard in pneumonia. 

Creaking, grazing sounds are heard in pleurisy, and indicate 
exudations upon the surfaces of the pleura. 

Metallic, tinkling sounds in pleural or pulmonary cavities mean 
pneumothorax, or the escape of air into some cavity. 

The abnormal sounds produced when the air breaks through 
impediments or passes over obstructions in the lungs, bronchi or 
trachea, are called rales (French raler, to rattle), and are said to be 
either moist or dry. 

Dry rales zviil usually be induced by a condition of the air passages 
in which they are not lubricated with the normal mucous secretion, or 
when it is inspissated or thickened; hence they are usually of a crack- 
ling or whistling character. 

Moist rales arc produced when the obstruction is fluid, and are 
apt to be of a bubbling nature. Peculiar conditions may, however, 
modify either of these, and special pulmonary diseases have their own 
specific rales. 

Cavernous rales are observed when there is a cavity filled with 
pus. 

Crepitant rales arc the crackling sounds symptomatic of the first 
stage of pneumonia. 

Mucous rales arc the bubbling sounds produced by the passage 
of air through bronchial mucus. 

Sibilant rales arc those that have a sharp, hissing sound, as when 
air passes through a contracted moist passage, or through foaming 
fluids. 

Sonorous rales are the stertorous, snoring sounds, as if the air 
were interrupted by some vibrating substance. 

Friction rales are the creaking sounds heard when, without the 
lubricating fluid that is natural to them, tzvo surfaces rub upon each 
other. 

Vesicular rales arc the Hue crepitant sounds heard in the vesicles 
of the lungs in the early stages of inflammation. 



PHYSICAL DIAGNOSIS. 277 

Sabcrepitant, or tracheal, rales are heard when mucus accumu- 
lates in the larger bronchi, or the trachea, and they form what is called 
the u death rattle." It is usually a premonitory symptom of dissolution. 

There are other murmurs heard in auscultation than those 
produced by the air in inspiration and expiration. They are caused 
by the movements of the blood current in the vessels, and by the 
friction produced by gliding surfaces in the organs of respiration 
and circulation. Sometimes the French term "bruit," having the 
same signification, is applied to them. 

The arterial murmur is the sound made by the arterial current, 
and it may be normal or disturbed. 

The cardiac murmur is the union of the systolic (contracting) 
and diastolic (dilating) sounds produced by the muscular actions of 
the heart and the passage of the blood through its auricles, ventricles, 
and valves. 

Hemic murmurs are the sounds due to changes in the quality and 
amount of the blood itself, and not to modifications in the vessels or 
valves. 

The venous murmurs are the so-called "bruit de diable" of the 
French, produced in the common jugular in anemia, lead-poisoning, etc. 

Artificial Respiration. 

The dentist will not infrequently be called upon to use artificial 
respiration, and a few plain, uncomplicated directions are necessary. 
Many persons each year are lost whose lives might readily enough 
be saved if this subject was better understood. No one should be 
< pronounced dead as long as there is the very slightest flutter of the 
heart, or when there is any vital warmth present. People have 
been restored after hours of unremitting efforts, unrewarded by 
even a gasp until near the end. Artificial respiration has held 
death at bay for days before any voluntary efforts could be induced. 

In cases of cessation of breathing not an instant should be lost 
in getting the patient into a prone or recumbent position, if he is 
not already so placed. All clothing should be loosened and the 
tongue seized with a pair of forceps, or a tenaculum, and forcibly 
drawn forward, at the same time raising the head a little to insure 
the opening of the glottis. In the absence of any such instrument 
any other suitable object may be thrust in the mouth and the 
base of the tongue pressed down and forward with it. Something 



278 ORAL PATHOLOGY AND PRACTICE. 

should then be placed under the patient's shoulders to raise the 
chest. The coat of the operator is excellent, if nothing else is at 
hand. 

The most simple and easily comprehensible method of pro- 
ducing artificial respiration is that called "Sylvester's," and either 
this or some other that is equally effective should be at once 
employed. The operator will place himself at the head of the 
unconscious person and seize the wrists. Then by a sweeping 
motion the arms should be extended, and at the same time hori- 
zontally carried to their fullest extent above the head. After an 
instant's interval they should be carried back by reversing the 
motion until they rest across the body just below the diaphragm, 
when firm pressure upward and against the body should be exerted. 
These motions should be continued about fifteen times per minute 
for an indefinite time, at the same time keeping up the bodily heat 
by the use of hot-water bottles, hot flannels, and chafing of the 
extremities. 

In cases of drowning, or the presence of fluid in the air 
passages, the body should first be held with the head down and 
the epiglottis be kept open to expel the water. Violent rolling 
upon a barrel or like object should never be practiced, as the 
shock may extinguish the lingering spark of life. Water will 
always run down hill if its course is unimpeded. It is well in 
such instances occasionally to interrupt the artificial respiration 
momentarily, turn the body on the side and depress the head, to 
allow the escape of any fluid that may have been expelled from 
the air passages. 

When there is sinking after the giving of an anesthetic, or in 
cocain or opium poisoning, artificial respiration may be necessary; 
but if breathing is once established the patient should be exercised 
as violently as practicable to assist the circulation and to aid in 
the elimination of the drug. A hypodermic injection of brandy 
may be administered, or one of ammonia. Strong coffee is an 
excellent antidote, as is any stimulant. Cocain poisoning will be 
manifested by symptoms very like those due to opium. People do 
not die of cocain poisoning except after the lapse of some time, 
as in poisoning from opium, and the narcotic effects are plainly 
visible before death ensues. The instances in which it is related 
that death occurred within a few moments after the injection of a 



THE ORAL TISSUES IN DIAGNOSIS. 279 

cocain solution were doubtless errors of diagnosis. The patient 
probably died of something else than narcotic poisoning. 



CHAPTER LX. 
THE ORAL TISSUES IN DIAGNOSIS. 

All gastric disturbances are reflected in the tissues of the 
mouth. The tongue especially is very expressive, and the oral 
physician or dentist should learn to read its indications as he would 
an open book. 

In health, the tongue is of a delicate whitish pink color, smooth 
and moist. Any departure from this appearance, either in the 
tongue or the other oral tissues, means a pathological state that 
demands the attention of a doctor. In another chapter, local 
inflammations with their symptoms have been described, and it 
remains but to give the appearance in general functional dis- 
turbances. 

The tongue is at times covered with a coating called "fur." 
This always indicates defective circulation of some kind. Fur 
consists of the unremoved epithelia of the mucous membrane, 
of the thickened, inspissated mucus, of the debris of food, or 
of some deposit. In pathological conditions the furring of the 
tongue is by regular gradations, commencing at the base and 
spreading toward the tip. In clearing up this is reversed, the 
clean spots first appearing at the end and sides, and spreading 
toward the base, so that by watching the progression or retrogres- 
sion of this process a fair knowledge of the progress of the disease 
may be obtained. 

Generally speaking, a dull whitish color of the tongue indicates 
a hyperacid condition ; while red, with fur, points to an alkaline or 
inflammatory state. 

A delicate whitish tint of the tongue within two hours after eating 
means that digestion is not completed. This tint should not be con- 
founded with disease indications. If the tint remains for more 
than four hours it means arrested digestion. 

White, with a thin coating, means acidity. A yellowish white, 
acidity with biliary irritation. A very white and thick coating 



28o ORAL PATHOLOGY AND PRACTICE. 

("flannel mouth") means intense venous congestion, as in cerebrospinal 
meningitis. 

Red, a delicate pinkish tinge, indicates that digestion is completed. 

Red of a deeper hue means arterial congestion. 

Red, a very deep and dark tinge, means the last condition very 
much exaggerated. 

Red, bright in color and raw or glased, indicates paralysis of the 
sympathetic — approaching fatal exhaustion. 

Brown, or brownish red, with a thick dry coating, means prostra- 
tion; arterial congestion; carbonic acid poisoning — a sign of danger. 

Black, or blackish, not deep, means blood poisoning — pyemia; 
sepsis. 

Blue, or a bluish tinge, indicates lack of oxygen; cyanosis. 

Humidity of the tongue means atony (lack of tone), with anemia. 

Dryness means nervous irritation; debility. 

Flabbiness, fullness, tremulousness, indicate great debility. 

Imperfect muscular movements, difficult articulation, means 
cerebrospinal irritation; drunkenness. 

There are exceptional conditions that are but temporary in 
character and not indicative of a real pathological degeneration. 
These must not be lost sight of, but must first be eliminated as 
causes in making a diagnosis. The following are instances : 

The tongue may be furred in health, as in excessive smoking. 

A dry tongue may be due to fever or to loss of sleep, or to 
excessive fatigue. 

In old age the tongue loses its diagnostic value to a great 
extent. 

In scarlet fever the desquamation may cause what is known as 
the "strawberry tongue." It is generally accompanied with des- 
quamation of the kidneys, etc. 

Depressing nervous impressions may cause a tremulousness 
and dryness that is but temporary, as in fright and great anxiety. 

Pleasurable sensations, the sight of food, etc., may induce a 
temporary humidity. "The mouth zvaters." 

It should be understood that it is not the tongue alone of the 
oral tissues that is indicative of the bodily state. Others may be 
equally expressive, and the judicious diagnostician will take them 
all into account in making up the sum of the objective symptoms. 



THE ORAL TISSUES IN DIAGNOSIS. 28l 

A red line, or red blotches, along the gums at a little distance from 
the margin is a diagnostic sign of pericemental or periosteal irritation. 

A still deeper red color, with excessive floiv of saliva, is found in 
ptyalism, or mercurialization. 

A blue line along the gums at the margin is indicative of lead 
poisoning. 

Great sponginess, sloughing of the gums, with fetor, indicate 
scurvy. 

Dark red gums, pufdness, everted edges, with oozing of pus, are 
found in pyorrhea! conditions. 

Purple gums, with a purulent discharge at more than one point, 
are indicative of caries or necrosis of bone. 

Gums hot and swollen, very tense, with a determination toward 
one point, mean suppuration, alveolar abscess, phlegmon. 

Gums inflamed and soft, with fluctuation, indicate the pressure of 
pus, which should be evacuated. 

Swollen gums, fetid discharge, mucous patches, shallow ulcers 
under the tongue, eruptions about the mouth, skin, and scalp, gums 
everted, with fetid matter about the necks of the teeth, the tongue per- 
haps swollen and flabby, with the edges scalloped by the pressure of 
the teeth, may be found in syphilitic conditions. 

It should be comprehended that not all these symptoms or 
appearances will be observed in one mouth, but any one of them 
should stimulate the dentist to further examination and inquiry. 

The indications of imminent danger as presented by the tongue 
are a tremulous action, dryness, blueness, very red, shining, or 
glazed aspect, heavy furring, dark or black hue — the so-called 
"black tongue." 

In considering the tongue and the oral tissues as diagnostic 
organs, the indications are not to be taken alone. The appearance 
should always be studied in connection with other symptoms, 
which may be the dominant ones, and may reverse the usual signi- 
fications. The oral tissues are to be considered as auxiliary, and 
not in every case pathognomonic. The diagnosis is to be reached 
by grouping all together, and reading one sign by the aid of the 
others. 






282 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LXI. 

WOUNDS AND INJURIES. 

A wound is a solution of continuity in the soft parts, suddenly 
produced. It is a rupture of the tissues by some form of mechanical 
violence, and may be produced by a direct or an indirect applica- 
tion of force. 

A wound may be a complete separation, with exposure of the 
tissues to external influences, or it may be a mere contusion, with- 
out any breaking of the integument. 

Wounds have their own train of symptoms, which are usually 
quite pronounced, so that, except in certain instances of deep- 
seated injuries, their diagnosis is comparatively easy. 

Wounds are distinguished by pain, hemorrhage, loss of 
function, shock, and, in injuries of the head, concussion. 

The pain is characteristic, and is usually proportional to the 
amount of the injury. When the tissues are crushed and there is 
deep contusion, the pain is sometimes very severe. 

The hemorrhage varies greatly with the vascularity of the 
tissue affected. All wounds must have some hemorrhage, for all 
soft tissues are supplied with blood. Even in case of a wheal, 
which is merely a stripe or a ridge upon the skin, such as follows 
the cut of a whip, there is usually more or less capillary bleeding. 

Loss of function differs with the location. It may be merely 
local or it may be general, varying with the extent of the injury 
and with the tissue involved. A single small muscle may be cut, 
as for instance the extensor of one of the digits, in which case the 
function of but one finger would be interfered with; or there may 
be such laceration of the muscles of the hand as to inhibit the 
action of all the fingers. 

Wounds are succeeded by traumatic "shock," which will be 
proportioned to the resistive force of the body at the time, the 
amount of injury, the location of the lesion, etc. The physical 
condition of the patient may be such as to make this very pro- 
found, or there may be a high condition of tonicity that will 
minimize it. The lesion may be in such vital organs 
that the constitutional disturbance will be great, or while 
considerable in extent the wound may be in tissues that 






WOUNDS AND INJURIES. 283, 

react but feebly. The age of the patient makes a material differ- 
ence in the amount of the consequent shock, and sex is an 
important factor, women suffering from it much less than men. 

Wounds are incised, lacerated, contused, punctured, per- 
forating-, gunshot, or poisoned. 

An incised wound is one made as with a sharp instrument. Its 
diagnosis is not always as easy as might be imagined, for a blow 
with a bludgeon may cause an incised wound if it be delivered over 
a bone with a sharp edge, in which instances the incision will be 
from beneath, and not from the surface; or the impact of a blunt 
instrument may be at such an angle as to produce a sharp rupture 
of the tissues. 

A lacerated wound is one in which the tissues are pulled apart. 
They are torn and ragged, and it is usually the result of an injury 
from compound causes, such as being caught in complicated 
machinery. 

A contused wound is one which is made with a blunt weapon. 
There is usually crushing of the tissues, without breaking of the 
skin. In such instances the connective tissue, with its inclosed 
vessels, always suffers. If but a few vessels are injured it is com- 
monly called a bruise. The hemorrhage consequent upon a con- 
tused wound is slight, and is usually limited to mere ecchymosis, 
or infiltration of blood into the tissues. The ordinary "black eye" 
is an instance of this. The blood extravasated into the cellular 
tissue assumes the dark venous hue, changes to a purplish black, 
then to a brownish green, finally assumes a yellow tint, and is 
absorbed. 

A punctured wound is one that is made into a cavity of the body. 
The gravity of a punctured wound depends upon the cavity that 
may be reached. Punctured wounds of the abdominal, the 
thoracic, or the cranial cavities are usually of a serious nature, 
owing to the danger of infection. 

A perforating wound' goes entirely through an organ or a tissue. 
The terms perforating and punctured are occasionally confused, 
some pathologists defining as punctured wounds those made by a 
pointed instrument, and perforating wounds those which reach to 
and open a cavity of the body. 

Gunshot wounds are those made by the discharge of -fire-arms. 
Works on surgery usually consider these as a distinct class, 



284 ORAL PATHOLOGY AND PRACTICE. 

because of the special complications in which they are apt to be 
involved. Not infrequently in gunshot wounds foreign substances 
are carried in, such as portions of the clothing, debris of the 
explosion, etc. Thus the danger of infection is greatly increased, 
and the irritation produced is much more violent. The impact of 
bullets, from their great velocity, increases the probability of shock, 
and at the same time too often disengages splinters of bone, which 
bring on new complications. The rotation of the rifled bullet adds 
to the amount of destruction of tissue, so that the track left by its 
passage, while very difficult to follow with a probe immediately 
after the injury, is peculiarly liable to be made manifest subse- 
quently, through the breaking down of the tissue. 

A poisoned wound is one that is infected with some mineral, 
vegetable, or animal poison. The most common of these are the 
bites of poisonous reptiles or insects, the stings of bees, wasps, etc., 
and the effects produced by the poison ivy, oak, and other toxic 
vegetables, as well as by bites of men and animals and infections by 
dirty tools. 

Wounds may be of a septic or aseptic character. In the former 
they have become infected with septic organisms, and there will be 
breaking down of tissue with suppuration, or the formation of pus. 
The septic bacteria are the greatest enemies the surgeon has to 
encounter in the treatment of wounds, and hence his chief efforts 
are directed toward the establishment of an aseptic, or sterile condi- 
tion. 

Wounds are healed by primary union, or, as it is often called, 
First Intention, by granulation or Second Intention, and by Third 
Intention. They are united by means of the fibrinous plastic 
exudate which is the result of the inflammatory process, and which 
earlier or later in the progress of healing agglutinates or unites the 
severed walls. 

Primary union or First Intention is the healing without infec- 
tion. There is no retrograde metamorphosis, or breaking down 
of tissue. There are no acute symptoms of any kind, and no 
granulation occurs. 

Granulation, or Second Intention, is the healing of a wound by 
the regular progressive additions of papillary or grain-like growths. 
Capillary loops form at the bottom of the cavity of the wound, 
and through them new tissue is developed. Upon the summit of 






TREATMENT OF WOUNDS. 285 

these, new capillary loops appear and new granulative tissue is 
formed, which follows the type of that from which it originated 
or to which it is to be joined, and this process is continued by 
''healing from the bottom," until the waste tissue is restored. 
(See Fig. 12.) 

Third Intention is the direct union of two surfaces on which 
granulation has already taken place. In fact, it does not in essential 
character differ from second intention, the granular or capillary 
loops being formed in the same manner, but there is less of 
cicatricial or scar tissue as the result. 

It should be borne in mind that this system of nomenclature 
is rather arbitrary, and in part founded upon hypotheses which are 
not fully accepted by modern pathologists. All healing in one 
sense is by a kind of granulation, but as this phenomenon presents 
certain distinct phases, and as the old system of nomenclature will 
doubtless be insisted on for some time to come, it has been retained 
with this explanation. 

When granulation becomes too exuberant it may continue 
above the surface, and is then commonly denoted "proud flesh." 
Usually, when the capillary loops reach the level of the surface, the 
fibrous exudate contracts and cuts off the blood supply, and the 
process is stopped. There is a proliferation of the epithelial cells, 
or a growth of the investing tissue over it, and it is thus covered 
with the dermal appendage, and the process completed. But, as 
has been stated, this may not take place, and in that case the result 
will be a hyperplasia, or excessive formation. For further study of 
the healing process the student is referred to the chapters on inflam- ' 
mation. 



CHAPTER LXII. 
TREATMENT OF WOUNDS. 



The healing of a wound is induced and incited by cleanliness 
and an aseptic condition. In treatment the first step, in the case of 
an open wound, is to remove any foreign substances. Especially 
in incised, lacerated, and gunshot wounds should careful examina- 
tion and, if necessary, exploration be made, to determine if any 
extraneous matter has been carried in by the instrument of injury. 



2&6 ORAL PATHOLOGY AND PRACTICE. 

If this is suspected, the wound must be carefully laid open to its 
extremest point, and thorough exploration made. There can be 
no healing so long as any particle of irritating foreign matter 
remains. 

In the case of a lacerated wound, the tissues should be carefully 
examined to determine the probability of the maintenance of the 
vascular supply in them. If the bloodvessels are so thoroughly 
destroyed that circulation will be completely cut off, such injured 
tissue must be removed, to obviate the dangers of gangrene. They 
cannot recover unless they are supplied with pabulum, and this is 
carried by the arteries. Hence, if there is no chance for the 
restoration of circulation in the part, amputation or excision is 
imperative, and should not be delayed. 

The destruction of an artery or vein does not by any means 
imply that circulation is entirely prevented, for it may be carried on 
through the collateral supply. It is only when all, or nearly all, 
the communicating tissue is so injured that its vessels can no 
longer convey a supply of blood that its removal is necessarily 
■demanded. Amputation of a part has sometimes been resorted 
to when the circulation might have been maintained, and when 
the vigor of the patient might have promised continued functional 
activity. 

The wound should be irrigated, and thoroughly washed out 
with a disinfecting and sterilizing fluid. It is sometimes necessary 
to use a great deal of judgment in selecting this. If the injury is 
very recent it is not well to use a mercuric chloride solution, 
because this may induce mercurial poisoning. Nor should carbolic 
acid or iodine be employed, as they may bring about carbolic or 
iodine poisoning. Preparations of hydronaphthol, formalin, or 
boric acid are preferable. If, however, there is an infected condi- 
tion and pus is present, the stronger germicides, like mercuric 
chloride I part to from 2000 to 4000 parts of water, may be em- 
ployed. 

It is not sufficient if only the interior of a wound is cleansed. 
The tissue about it should be carefully washed with an anti- 
septic fluid, and all foreign matters removed. If the edges are 
surrounded by hair, this must be clipped or shaved off, that it 
may not harbor any impurities, and everything that might cause 
irritation must be needfully eliminated. 



TREATMENT OF WOUNDS. 287 

No operations about a wound are permissible without the most 
stringent antiseptic precautions. All the sponges and cloths used 
must be sterilized. The hands of the surgeon must be thoroughly 
washed with aseptic soap, all matter under the nails being removed, 
and finally they must be drenched with an antiseptic mixture, or 
washed with ground mustard used in place of soap. 

A broad and shallow vessel partly filled with a solution of car- 
bolic acid, hydronaphthol, formalin, or some other good anti- 
septic, should be provided for all instruments used, and these must 
frequently be dropped into it. Especially if any instrument or 
sponge should happen to come in contact with any unsterilized 
body, as by an accidental dropping upon the floor, must it be given 
a bath in the sterilizing tray. 

If the hemorrhage from a wound is light in color, or if it issues 
by distinct spurts, it is arterial. If dark in color and steady in its 
flow it is venous; if merely oozing it is capillary. Either may be 
controlled by means of the hemostatic forceps, and by ligatures. 
Enough of the former instruments should be kept in the sterilizing 
solution for any emergency. With one of these the mouth of a 
bleeding artery or vein is seized, the handles are locked, and it is 
allowed to remain in position until the close of the operation. If 
the bleeding has not then been stopped by the contraction of the 
muscular coats, a ligature may be passed about the vessel and the 
ends allowed to protrude from the wound. 

When the bleeding is capillary, it may be necessary to pass a 
ligature around a portion of the tissue for the purpose of arresting 
it. When it is venous, it is sometimes sufficient to seize the 
mouths of the vessels with one pair of artery forceps, draw them 
out sufficiently to allow of grasping them with a second pair, and 
then to close them by torsion or twisting. 

For controlling the hemorrhage caused by the severing of 
important arteries, the only effective means is the ligature, the 
application of which sometimes demands expert knowledge and 
judgment. Great injury may be done by unskillful ligation. In 
the larger vessels, the arteries, veins, and nerves may be within the 
same sheath, which is but an infolding of the fascia ; and there may 
be more than one vein. Before ligating, the sheath should be 
opened and the vessel to be tied dissected out. The ligature should 
be passed about it, and fastened with a square knot to prevent 



288 ORAL PATHOLOGY AND PRACTICE. 

slipping. The knot should be drawn firmly, but not too tight, lest 
the outer coat of the vessel be cut, and sloughing and secondary 
hemorrhage be the result. An artery should not be drawn out of 
its sheath any farther than is necessary to allow of tying, because in 
so doing its future nutrition may be interfered with, through sepa- 
ration of or injury to the vaso-motor nerves. 

Immediate or mediate compression may be used for stopping 
the flow of blood temporarily when it is excessive. 

Immediate compression is accomplished by packing the wound 
unth lint, and then applying a compress or bandage. 

Mediate compression is -when pressure is made upon the artery 
between the wound and the heart. Any firm substance is placed 
over the artery, and then a bandage or tourniquet is twisted very 
firmly about the part until the bleeding is controlled. 

The control of bleeding by acupuncture is sometimes neces- 
sary in aged persons, the muscular coats of whose arteries are too- 
weak to withstand the ligature. This consists, in transfixing the 
tissues with an acupuncture needle, and then winding about it a 
ligature in such a manner as to produce local compression. 

Aneurisms may be formed through, injuries to arteries, when 
some of their coats are divided and there is dilatation of those which 
remain unpunctured. In their earlier stages aneurisms may be 
diagnosed by the distinct pulsations within them, but later this 
may be masked by the thick felt of blood coagulum which forms 
within. A tumor in the immediate neighborhood of an artery 
should be opened with extreme caution, lest it prove of an aneur- 
ismal character. • 

The ligating of an artery, when skillfully done, does not 
deprive the tissues dependent upon it of their vascular supply, as 
sufficient collateral circulation is soon established. This takes 
place through an enlargement of the communicating and anasto- 
mosing smaller arteries given off above and below the wound, 
until they are sufficient to convey the volume of blood originally 
carried by the divided vessel. 

A wound having been cleansed and irrigated, and the hemor- 
rhage having been completely controlled, the next step is to close it. 
If the gaping is considerable, it may be necessary to sew it up. 
This is done with sutures of catgut if it is deep, or with silk if more 
shallow. The stitches are made with suture needles of differing 



TREATMENT OF WOUNDS. 250, 

shapes, which may be passed by means of needle forceps. All 
ligatures or sutures must be thoroughly sterilized before using. 
The depth of the stitches must be proportioned to the depth of the 
wound. . If this is considerable, it may be advisable first to insert 
a few catgut sutures to hold in place the deeper tissues. The final 
closing ones are always superficial, and they should be near enough 
together to prevent any gaping of the edges. The closing stitches 
should be carefully made, so that there will be no drawing of the 
integument, the borders of the wound being left in smooth coapta- 
tion. They are to be removed as soon as there is sufficient union 
to prevent the separation of the edges. This will be within a very 
few days, if all goes well. Sometimes it is necessary to use deep 
retentive sutures to prevent undue tension upon the closing 
stitches. They have their insertion at some distance from the 
margin of the wound, and each end is attached to a button, so that 
they will not be likely to cut through the tissues. 

If the wound has become infected with septic organisms, or if 
there is good reason to suspect that it will be impossible to keep it 
aseptic, it may be necessary to insert a drainage tube before com- 
pletely closing it. This may be of sterilized rubber, or of decalci- 
fied bone; or it may be only some strands of silk or 
gauze, carried to the deep portion of the wound and allowed 
to come to the surface; and its size should be propor- 
tioned to the amount of probable discharge. The drainage tube 
offers a ready means of escape for pus or sanious matter, secretions 
of glands, or the products of inflammation. If the tube penetrates 
to a cavity of the body, some effective means, like a ligature or the 
insertion of a safety pin, must be employed to prevent its being 
drawn into the cavity. To retain it and keep it from slipping out, 
it may be held by the external dressings, by adhesive strips, or 
other convenient means. The drainage tube is to be left in place 
as long as there is a necessity for its presence. Sometimes it is of 
great convenience in irrigating or washing out the wound. 

The final dressing of a wound should be with antiseptics. 
After terminal washing and cleansing of the exterior with an 
antiseptic fluid the surface is usually dusted with aristol, acetanilid, 
or iodoform. A piece of antiseptic gauze is then superimposed, 
and upon this sterilized cotton batting, in quantity sufficient to 
make a thick pad. The wounded organ may then be bandaged, 



29O ORAL PATHOLOGY AND PRACTICE. 

and placed in a sling or support if required. The dressings may 
be removed when necessary, but should not be disturbed by med- 
dlesome interference. 

Poisoned wounds that are of a serious character, such as the 
bites of venomous serpents, should be immediately ligated to pre- 
vent the spread of the poison in the blood, and then be thoroughly 
cauterized. The latter may be effected by the actual cautery or 
by cauterizing agents like silver nitrate or chromic acid. An 
effectual though not agreeable way is to burn gunpowder upon 
the wounded surface. This may be practicable in case of accidents 
when no other cauterizing agent is at hand. 

The after treatment of wounds consists in the exercise of the 
most watchful care to avoid septic infection, or to combat it when 
present. All dressings must be kept clean and in place, and 
changed if necessary to accomplish this. But meddlesome inter- 
ference must be avoided, and no dressing should be removed unless 
there is good cause for it. When the organizable lymph has been 
effused it must be protected and kept aseptic. Every sanitary 
precaution should be observed, and the patient sustained with a 
nourishing diet. A wounded limb must be kept quiet and 
muscular action prevented, except so far as motion of joints, etc., 
is required to prevent ankylosis. 



CHAPTER LXIII. 
EXCESSIVE BLEEDING. 



There is nothing in dental practice that is more alarming, 
especially to the young practitioner, than to have follow an opera- 
tion an unusual flow of blood which cannot readily be checked. 
Too many lose fheir presence of mind at such times, become con- 
fused and distracted, exhibit this in their manner, and thereby alarm 
both patient and attending friends. A physician is perhaps called, 
who assumes direction of affairs, and the dentist is relegated to a 
subordinate position. As a consequence he is humiliated and loses 
the confidence of all who are witnesses. Exaggerated accounts of 
the matter are circulated from mouth to mouth, and his profes- 
sional reputation may thus be irretrievably injured in the commu- 



EXCESSIVE BLEEDING. 29 1 

nity. All this may at any time be the consequence of lack of 
knowledge, or a deficiency in professional self-confidence. In any 
sudden emergency the most important requisite on the part of the 
doctor is self-possession, and the entire command of his own 
powers. 

The first thing to consider in cases of hemorrhage is whether it 
is arterial, venous, or capillary. If the former, the blood will be a 
bright red, and will issue from the wound in jets, synchronous with 
the heart-beats. If it is venous, the blood will be darker in color 
and will well up continuously. If it is capillary, there will be a 
slow oozing from the edges, which will appear again as it is wiped 
away. This, while the least alarming in appearance, is really the 
most threatening, because it may be the result of a hemorrhagic 
diathesis. 

Arterial bleeding may always be checked by ligation of the 
artery. Usually, however, unless the vessel is an important one j 
it will be sufficient to wipe away the blood with a sponge until the 
mouth of the severed vessel is found, when it should be grasped: 
with a pair of artery forceps, which are at once locked upon it. In 
their absence the mouth of the artery or vein, with a little of the 
surrounding tissue, may be seized with any suitable pliers, and the 
whole twisted and pinched until the coats of the vessel contract 
sufficiently to stop the bleeding. Sometimes a waxed silk ligature 
passed around it and closely tied is preferable. 

If the bleeding is from the socket of an extracted tooth a 
pledget of cotton, or lint, or sponge that has been dipped in tannic 
acid, or, in its absence, in powdered alum, or red pepper, or in a 
solution of iodine, turpentine, capsicum, or even dilute sulphuric 
acid, should be closely packed at the bottom, and on that a cork, cut 
to a conical form that shall fit the socket, should be placed in such a 
manner as to project sufficiently for the occluding tooth to shut 
firmly upon it. A two-tailed bandage may now be used firmly to 
press up the lower jaw and hold the cork in position. This should 
be left for some hours at least, when the bandage and cork may be 
carefully removed, leaving the cotton until it loosens itself. 

If the bleeding is distinctly venous the same methods may be 
employed, but the emergency will not probably be as great. Arterial 
bleeding will be certain to receive attention, but the smaller veins 
may continue open, and there may be a steady loss of blood for 



292 



ORAL PATHOLOGY AND PRACTICE. 



hours, which will gradually weaken the patient. If this is the 
case, an examination should be made to determine whether the 
bleeding is from the small veins or is distinctly capillary. If the 
former the points of its issue may be readily determined, but if it is 
the latter there will be a slow oozing from the tissues without any 
distinct point of exit. 

If it is capillary hemorrhage, the condition will demand the 
greatest care and cause the most anxiety. Strips of cotton wet with 
a tannic acid solution, or a ten per cent, solution of antipyrine, 
or with one of the other hemostatics named, should be adjusted 
over the wound, if on the surface, and bandaged to place if 
possible. Monsell's solution of perchloride of iron should not be 
used in the mouth, nor should any active cauterants be employed. 
Tannic acid, in doses of one to four grains, may be administered in 
water every two hours in extreme cases. Or, of the aqueous 
extract of erigeron, from five to ten grains may be administered 
every two hours. Or from fifteen to thirty drops of tinct. of ergot 
may be given every hour until the bleeding ceases. The feet 
should also be placed in hot water for half an hour. Veratrum 
viride, as an arterial sedative, in doses of two to five drops every 
two hours, will frequently prove useful. 

In the so-called hemorrhagic diathesis the tendency toward 
capillary bleeding is due either to some abnormal condition, the 
result of a distinct dyscrasia, or to a lack of tone in the system. It 
seems to be idiosyncratic with some. When either of these is the 
cause it may demand more than a general knowledge of the sub- 
ject, and the family physician should be called to learn whether 
there exists any special cachectic condition. If this is the case it 
will, of course, be turned over to him. Anemia, purpura, scrofula, 
typhoid, and other diatheses tend to induce excessive bleeding, 
and in their presence great care should be used. If there is any 
special idiosyncrasy the patient will probably know of it, and 
should warn the dentist before any operation is commenced. 



FRACTURES AND THEIR TREATMENT. 293 

CHAPTER LXIV. 
FRACTURES AND THEIR TREATMENT. 

The consideration of fractures should properly be taken up in 
connection with surgical procedures. But, as cases of injury to 
the jaw and head may at any time fall into the hands of the dental 
practitioner, this work would be incomplete if their pathology was 
not in an epitomized manner given some attention. More than 
this is not attempted. 

A fracture is a solution or rupture of continuity in bone or 
cartilage. What wounds are to soft tissues, such are fractures to 
the framework of the body. They form one-seventh of all the 
injuries to which human beings are liable. They are ten times as 
frequent as dislocations. They are of all degrees of severity, from 
the mere indentation or irregular depression of a flat bone to the 
complete comminution of long bones. The character of the frac- 
ture will depend upon the force which produced it and the shape of 
the bone itself. Thus, in irregular bones the fracture is usually a 
compression, while in long bones it is likely to be a complete 
separation, with more or less displacement of the fragments. 

Fractures may be produced by external violence or by internal 
muscular action. Probably a much greater proportion of them are 
caused by the latter than would be readily imagined. In falling 
from a considerable height the muscles may be so spasmodically 
contracted as to break the bones of their attachment before the 
individual strikes the ground. 

The strength of bones, and therefore their ability to with- 
stand injuries, depends upon their texture. Compact tissue is. 
stronger than that which is cancellous, and the bones of different 
individuals greatly vary. So also does the strength of a bone 
alter with the physical condition, certain diatheses predisposing to- 
weakness, until perhaps in some extreme instances they yield to- 
comparatively slight muscular exertion, and break almost spon- 
taneously. The shape of bones has also much to do with their 
strength, the long and flat being more liable to fracture than the 
irregular. 

The bones of males are stronger than those of females, but 



294 



ORAL PATHOLOGY AND PRACTICE. 



they are more exposed to accident. Age has much to do with the 
resisting power of the different parts of the skeleton, those of older 
people being more brittle. Weak points, or curves, largely deter- 

Fig. 95- 





Bony Ankylosis of the Elbow Joint. 



FRACTURES AND THEIR TREATMENT. 295 

mine the course of fractures, especially when they are the result 
of muscular action. 

Fractures of the bones are said to be either Simple, Compound, 
or Complicated. 

A simple fracture is one in which the skin or mucous membrane 
is not ruptured, and there is no serious injury to the investing tissue. 

A compound fracture is one in zvhich there is a communication 
through the skin, or exposure of the bone to the air, with the pos- 
sibility of infection. 

A complicated fracture is one in which other tissues are involved 
in the injury. 

Fractures are also classed by surgeons as Complete and Incom- 
plete. 

A complete fracture is one in which there is a separation of 
the body of the bone into two or more fragments. Complete frac- 
tures may be divided as follows : 

A Transverse Fracture is one that is at nearly right angles to 
the axis of the bone. 

An Oblique Fracture is one that is at an angle of ten or more 
degrees. 

A Longitudinal Fracture is one that is at an angle of more than 
seventy degrees. 

An Epiphyseal Fracture is a fracture of the cartilage which unites 
the epiphysis, or extremity, to the shaft of a bone. Of course it can 
only occur in young persons. 

A Multiple Fracture is one in which the bone is separated into a 
number of fragments. 

An Impacted Fracture is when one fragment penetrates another, 
thus preventing their free movement. 

A Comminuted Fracture is one in which the bone is shattered, or 
separated into fine particles. 

An incomplete fracture is when there is not an entire separa- 
tion of the body of the bone, but either it stops short of that or 
consists in the breaking off of a portion. Incomplete fractures may 
be classified as follows: 

A Fracture of the Apophysis is the separation of that process 
from the shaft. 

A Detached Fracture is the separation of a fragment, as by a 
cutting instrument. 



296 ORAL PATHOLOGY AND PRACTICE. 

Fracture of the Malleolus is a separation of the hammer-shaped 
head of a bone, the body or shaft remaining intact. 

A Green-stick Fracture is what its name indicates: the splintering 
of a bone without its entire separation. This is necessarily mainly- 
confined to long bones, and to young persons. 

A Fissured Fracture is the opening of a crack in one plate of a 
bone, as in certain fractures of the crania. 

A Depressed Fracture is when a dent is made in the table of a 
bone, a part being thus displaced without entire separation. 

The diagnosis of fracture, although usually easy, may be ex- 
ceedingly difficult. The symptoms presented are both objective and 
subjective. They may be arranged under the following heads: 

History of the predisposing or immediate cause. This should 
always be carefully inquired into, especially if the force seems 
inadequate to the production of the injury. 

Localised pain and tenderness. This may be determined by 
pressure and digital manipulation. 

Crepitus, or Crepitation. This is the grating of one fractured 
end upon another, and is determined by careful movements of the 
parts. In impacted fractures this means of diagnosis is elimi- 
nated, and hence it may be difficult to arrive at a conclusion. 

Abnormal mobility. It is sometimes almost impossible to 
determine this in the neighborhood of joints, unless crepitus is 
present. 

Consequent deformity. This may be partially or completely 
masked by the swelling consequent upon the injury. 

Comparison of two sides. This is very important in determin- 
ing the deformity, but a possible asymmetry may lead one astray, 
unless caution is used. 

When the deformity is reduced it will not remain so, but the parts 
zcill separate and reproduce it. This will distinguish a certain class 
of luxations from fractures. 

Anesthesia is sometimes necessary in making a diagnosis, 
owing to the resistance of muscular action. 

Treatment of Fractures. 
Bones very readily unite when their injuries are properly 
treated. Reduction is the first thing to be accomplished. If 
there are no complications, and if the fractured ends are firmly 



FRACTURES AND THEIR TREATMENT. 297 

held in apposition, there will be a deposit of plastic lymph — in this 
instance usually called provisional callus — about the injured ex- 
tremities. This assumes a cartilaginous form, and in due time 
ossifies and firmly unites the fragments, the process demanding 
from four to eight weeks. There will necessarily be some tem- 
porary enlargement and deformity, which will greatly depend upon 
the amount of displacement. In time, as the newly formed tissue 
becomes fully organized, the projecting portions will be resorbed, 
and the irregular surfaces thus made more symmetrical. 

Before the final reduction any muscular injury must be at- 
tended to, and if there are complications, such as involvement of a 
joint or injury to a contained organ, or comminution of the bone, 
these must be looked after. 

The greatest obstacle to reduction and retention will be the 
muscular contraction consequent upon the injury. This must be 
controlled by traction and counter-traction. A steadily applied, 
moderate force must be brought to bear upon the muscles until 
they gradually yield. Violence will only increase the contraction, 
but a gentle, persistent force, like that of a weight, will after a time 
tire the muscles out, when they will readily give way. 

Oblique fractures usually need only extension for their reduc- 
tion. Transverse fractures with displacement require also manipu- 
lation. 

When reduction is accomplished, the parts are usually held in 
place by splints or bandages. Absolute immobility is not required, 
as slight motion is beneficial, owing to the fact that it is a stimulus 
to functional activity, but this must not be sufficient to interfere 
with the deposition and organization of the provisional callus. 

In the treatment of compound fractures, the wound must be 
considered as an open one, and the instructions given in 
Chapter LXIL, Treatment of Wounds, should be kept in mind. 
Thorough asepsis must be secured if possible. An anesthetic 
may be administered and the injury thoroughly explored 
for the removal of all comminuted fragments, blood-clots, 
and foreign matter. A drainage tube may be inserted if desirable, 
and the wound left open at its center. 

Delayed union, or non-union, may exist when the plastic exu- 
date is not promptly thrown out, or being deposited is not organized. 
Perhaps the circulation or nutrition is impaired. This condition 



298 



ORAL PATHOLOGY AND PRACTICE. 



should be attentively looked after. The ends of the bone may be 
rubbed together if necessary, to stimulate functional activity. 

Delayed union may result in the formation of a "false joint," or a 
fibrous union. In such instances it will be necessary to break this 
up, and perhaps to bore the ends of the bone, or scrape them, to 
induce a new osseous formation. 

Fig. 96. 




Fibrous Ankylosis of a Joint. 



Non-union may be the result of a neglect properly to reduce the 
fracture. The ends of the bone may become rounded off by re- 
sorption and the medulla be closed. The remedy in such in- 
stances is to open the seat of the fracture, saw off the ends of the 
bone, and depend upon a new formation after reduction. 

In fractures of the long bones, shortening is likely to be the 
result of muscular contraction and the overlapping of the ends of 
the fragments, unless extension is used. 



SPECIAL CASES OF FRACTURE. 



299 



CHAPTER LXV. 

SPECIAL CASES OF FRACTURE. 

Fractures of the nasal bones may be determined by the deform- 
ity, by the infiltration or emphysema of the investing tissues, by 
crepitus, and through obstruction of the nasal passages by blood- 
clots. They are not dangerous unless the injury is at the base, 
when the cribriform plate of the ethmoid may be injured, and a 
shock thus given to the brain. The adjustment must usually be 
by means of directors or needles thrust up the nostril, and the 
parts are held in place by adhesive strips. 

Fig. 97. 




A Simple but Effectual Method of Wiring the Teeth Together for the Purpose 
of Reducing a Fracture. 

Fractures of the superior maxilla and of the alveolar process 
may be met with. If they are incomplete and there is no special 
deformity they have little' significance. The nasal and alveolar 
processes are frequently broken. The former may be a complica- 
tion of injuries to the nasal bones. The latter may be broken in 
careless extraction of the teeth. It very readily unites, and usually 
requires little attention unless a small fragment is displaced, in 
which case it should be removed. 

Fractures of the body of the superior maxilla may result from 
great violence. There is no bone which so readily unites, and all 
that is usually necessary is to reduce the fracture as completely as 



300 ORAL PATHOLOGY AND PRACTICE. 

possible, and retain the parts in apposition by bandages and ad- 
hesive strips. When the injury is considerable, the adjustment 
may sometimes be made by getting the teeth in alignment, and 
retaining them by ligatures, gold bands, or even an artificial palatal 
plate. 

The antrum may be involved in fractures of the superior 
maxilla, and this may introduce a complication that may embarrass 
the treatment. In such a case the directions given in Chapter 
XXXV., on Diseases of the Maxillary Sinus, should be observed. 

The hemorrhage in fractures of the maxilla is not usually 
serious, and it will not be difficult to control. 

Fractures of the inferior maxilla are three times as common as 
those of the superior. This is because of their increased liability 
to accident through their greater exposure. The fractures are 
most often those of the body, although the ramus may be the seat 
of the injury. 

The diagnosis is easy, except when the injury is to the coro- 
noid process or the ramus. The symptoms are pain, deformity,, 
mobility, and crepitus. The teeth form a most important auxiliary 
in both diagnosis and treatment. Observation of the position of 
the jaws and the occlusion of the teeth, if the latter are present, will 
ordinarily be sufficient to determine the amount of injury and the 
best method of reduction. 

The treatment of all such cases is best accomplished by the 
dentist, because he is familiar with the normal condition of the 
organs involved, and he has the mechanical skill to construct the 
appliance which will best reduce the displacement and retain the 
fragments in proper apposition. Too often the proper function of 
the teeth is lost through lack of the knowledge how to secure their 
proper alignment, or so to retain the fragments that normal occlu- 
sion will be secured when healing is complete. 

Various forms of splints have been devised by ingenious 
dentists for the treatment of fractures of the inferior maxilla. 
Some have held the fragments in apposition with the upper jaw by 
banding the opposite or occluding teeth on each side of the line of 
fracture, and then holding them together firmly by means of a 
connecting screw or clamp. 

Various devices for wiring the teeth together have been pro- 
posed. The general surgeon has in the past mainly depended upon 
this method of retention. 



SPECIAL CASES OF FRACTURE. 3OI 

Skull caps, with fixed or elastic bandages passing- around the 
lower jaw, have been employed. 

Where there are enough of teeth in each jaw to serve the 
purpose, an excellent method for reducing and holding in place 
the fragments is simply to place around convenient teeth silver 
wires, and then twist those opposite each other together until 
the teeth are in correct apposition and held firmly in occlusion. 
The twisted ends may be covered with small rubber tubing and 
bent down closely, to prevent their lacerating the buccal tissues. 
The jaws are thus held together until union has taken place, 
If no teeth have been lost, so that feeding can be through the 

Fig. 98. 



Swaged Aluminum Splint to be Cemented in Position. 
Its borders between the teeth can be pinched together so as to hold the fractured parts 
firmly in position. The swage is made from a plaster cast that has been sawed apart at the 
points of fracture and afterward properly adjusted. 

vacancies, it is always possible to carry sufficient food into the 
mouth through the space posterior to the molars, liquids being 
mainly used. (See Fig. 97.) 

One of the most effectual methods is the employment of 
some form of the interdental splint. An impression of the frac- 
tured jaw is taken in some plastic material, without any attempt at 
replacement of the fragments. A cast of this is made in plaster of 
Paris, which gives a counterpart of the deformed jaw. Another 
impression and cast of the occluding jaw and teeth is secured. A 
fine saw is run through the cast of the broken jaw at the point or 
points of injury, and the pieces placed in proper apposition with the 
cast of the superior teeth, when they are fastened by running 
plaster of Paris about them. They are placed in an articulator 
and a wax model of a splint is made for the lower jaw which will 



302 



ORAL PATHOLOGY AND PRACTICE. 



properly occlude with the teeth of the upper jaw, so that mastica- 
tion may be possible during the process of healing. 

The wax model is reproduced in vulcanite, and when the frag- 
ments of the broken jaw are adjusted to it they may be retained in 
various ways. In the case of one such fracture of the jaw of a 
noted pugilist treated by the author, which had remained unre- 
duced for some weeks, nothing more was needed than the insertion 
of four gold screws through the outer plate of the splint, which 
obtained their hold in the V-shaped space between two teeth that 
were close together. Although this case demanded a subsequent 
operation from the outside for the removal of comminuted frag- 
ments, it was not found necessary to remove the splint until healing 
was complete. 

Fig. 99. 




Method of Holding in Position the Parts of a Jaw Fractured at the Symphysis. 

(Angle.) 

In another case, one of fracture of both the upper and lower 
jaws in a boy of fourteen, the splint consisted of a gutta-percha 
impression of each jaw, trimmed to proper shape. After their prep- 
aration, and immediately before their insertion, the occluding sur- 
faces were warmed so that they would adhere together when reduc- 
tion was accomplished, an elliptical opening between the anterior 
teeth being made for the purpose of feeding. The adjusting of the 
parts and the insertion of the splints, with the necessary band- 
aging, was accomplished under chloroform. The whole work, in- 
cluding the taking of the impressions, the fashioning of the splints, 
and the reduction, occupied less than an hour, although three very 
competent physicians and an accomplished surgeon had vainly kept 
the boy under an anesthetic for more than four hours previously. 
Their failure was solely due to their inability to construct a splint 
that would hold the parts in apposition when they had the different 



DISLOCATIONS AND SPRAINS. 3O3 

fractures reduced, and not of course to any lack of surgical skill or 
knowledge. 

The judicious and ingenious dentist will readily devise an 
appliance that will be sufficient to retain the fragments in any form 
of injuries to the jaws. Xo two cases present precisely identical 
conditions, or require the same treatment, and he will vary his 
appurtenance so that it will meet the required ends. 

It is no part of the scope of this work to give instructions for 
the mechanical manufacture of splints, interdental or otherwise. 



CHAPTER LXVI. 
DISLOCATIONS AND SPRAINS. 

A Dislocation is the complete or partial separation of the articu- 
lar surface of one bone from that of another, or the displacement 
of an organ from its natural position. 

That which will most frequently be met in the practice of 
the dentist is the luxation of the lower jaw. This may occur in 
extraction or in other operations, and not infrequently it may be 
spontaneous and happen in gaping or yawning. Some people are 
liable to it on slight provocation, the condyle easily slipping out 
of the glenoid fossa. 

Joints or articulations are movable and immovable or fixed. 

If movable, they are complex in their structure and are united by 
flexible ligaments. 

If slightly movable, they are usually connected with fibro-cartilage f 
which is tough, elastic, and pliant. 

If immovable, they arc connected by mere membranous sutural 
ligaments. 

Sometimes the union of fibro-cartilage is so firm that only a 
fracture can cause displacement. 

The ends of articulated bones, if the joint is a movable one, 
are enlarged and made up of compact tissue, the lamellae differing 
from those of the other parts, being without Haversian canals. 
The nutrition thus being less complete, they are more apt to die. 

Articular cartilage covers the ends of bones, and, as has been 
said, fibro-cartilage. separates certain of the joints, such as the 



304 ORAL PATHOLOGY AND PRACTICE. 

vertebrae. A man is half an inch taller in the morning than at 
night, because during the day, when he is in an upright position, 
the interarticular fibro-cartilage becomes compressed. 

A ligament is a band of compact membranous tissue connecting 
the articular ends of bones, and sometimes enveloping them in a capsule. 
It is not the office of the ligament to< hold the bones together; 
that is the function of the muscles, the ligament merely limiting 
and restraining the motion, preventing it from going too far. 

The synovial membrane is a short membranous tube inclosing 
the joint, attached at the edges of the cartilage, and secreting the 
synovia, or synovial fluid, for the lubrication of the joint. 

When there are many muscles and great flexibility is de- 
manded, as in the wrist, there is very seldom a dislocation. 

Dislocations are traumatic, pathological, or congenital. 

Traumatic dislocations are the result of external violence or of 
muscular action. They are by far the most frequent of any. 

Pathological dislocations are the result of the destruction of a 
part of the artiadation by disease. 

Congenital dislocations are those in which some essential part 
of the joint has never developed, and hence they are irreducible. 

Dislocations, like fractures, may be simple, or compound, or 
complicated. 

A simple dislocation is one in which there is displacement, zvithout 
injury to any tissue. 

A compound dislocation is one in which there is a wound that 
exposes some part of the articulation to the air. 

A± complicated dislocation is one in which important nerves, blood- 
vessels, or other tissues are involved in the injury. Complicated dis- 
locations are fortunately infrequent. 

The symptoms of dislocation are much the same as those of 
fracture. They are as follows : 

Deformity. This will be evident from the unnatural position 
of the bone, and from the tumor which will be the result. 

Pain. This may be quite severe, and it will be located at the 
position of the joint. It will probably be of a dull, sickening 
character, and it is worse than that of a fracture. 

Rigidity. This will arise from the fixation of the parts, the 
voluntary movements being entirely absent or very much limited. 

New position of the bone. This may often be traced through 



DISLOCATIONS AND SPRAINS. 305 

the tissues by digital, or even, in some cases, ocular examina- 
tion. The axis of the bone is altered and all its relations 
are modified. Usually there is lengthening or shortening, as in 
fractures. 

Dislocations are differentiated from fractures by the immo- 
bility of the former, the absence of crepitus, and by the general 
appearance, the character of the pain, etc. 

In dislocations there is usually complete fixation with no 
power of voluntary movement. In fractures, on the contrary, 
there is apt to be abnormal movement which is not under volun- 
tary muscular control. 

Dislocations are treated first by reduction. This is best 
secured by manipulation, whenever that is possible. 

If the ligaments are badly torn and the luxation is thus com- 
plicated, manipulation may cause exceeding pain, and an anesthetic 
may be necessary. 

Sometimes in old dislocations there have been exudation and 
partial organization of the product, with perhaps more or less of 
bony ankylosis (see Fig. 95) ; or, more probably, fibrous anky- 
losis may have been formed, so that it is impossible to obtain 
reduction without surgical help (see Fig. 96). In these cases 
it may be necessary to open the joint and break up the union. 
This must, of course, be done under the strictest antiseptic pre- 
cautions. 

Dislocation of the inferior maxilla may be unilateral, involv- 
ing but one side, or what is more frequent, bilateral, with forward 
displacement. It consists in a slipping forward of the condyle from 
the glenoid fossa, over the eminentia articularis. It occurs only 
when the mouth is widely opened. The external pterygoid muscle 
becomes violently flexed, and draws the condyle forward upon the 
surface of the bone. The temporal muscle becomes rigid, and 
helps to hold the condyle in its false position. The interarticular 
cartilage is carried forward with the condyle, but the capsular 
ligament is not usually torn. (See Fig. 100.) 

The symptoms of luxation of the inferior maxilla are a rigidity 
of the jaw, with inability to move it or to close the mouth. There is 
a marked projection of the chin, and the condyle may be felt for- 
ward of its normal position. If it is unilateral there is a deviation 
of the jaw toward the uninjured side. 



306 



ORAL PATHOLOGY AND PRACTICE. 



The reduction of the dislocation is effected by supporting the 
symphysis, and at the same time depressing the angles of the jaw, 
the object being to carry the condyle downward and backward 
until it will slip over the articular eminence. The operator should 
stand in front of the patient, and, the thumbs being protected by 
wrapping around them a handkerchief, the jaw is firmly grasped 
with both hands, the protected thumbs being placed far back over 
the molar teeth. Then, by pressing down with the thumbs and 
supporting the symphysis with the ends of the fingers, the jaw 
may usually be carried to place, the condyle slipping into the 
glenoid fossa with a distinct snap, and the jaw closing with con- 
siderable violence. 

Fig. ioo. 




Dislocation of the Lower Jaw, showing the Anatomical Relation of the Parts. 

(After Sir A. Cooper.) 



Sometimes it may be necessary to use a stout piece of wood 
between the back teeth as a lever to carry the condyle down and 
back, the angle being supported with the hand. This method will 
be found especially useful in unilateral luxations. Some kind of a 
pad should always be placed between the teeth of the two jaws, to 
prevent their being broken with the violence of the closure when 
the reduction is made. 

Dislocation of the lower jaw backward sometimes occurs, but 
only as the result of great violence, and is necessarily accompanied 
by fracture of the borders of the fossa. The dislocation in this case 
:becomes of less importance than the other injury, and its reduction 
is subordinate to the other treatment. 



SHOCK COLLAPSE. 307 

A Sprain is a self -reduced dislocation, with consequent soreness 
from the violent strain upon the muscles and tendons, and with pos- 
sible laceration of the ligaments or attachments. It is characterized 
by severe pain, much increased by movement, with rapid swelling 
and heat in the joint. Sprains are usually treated by either hot 
fomentations or cold applications, whichever seems indicated. 
The former will be likely to bring about resolution, while the latter 
will be demanded when there is a great deal of heat and an intense 
hyperemia. If the swelling is very great, through excessive effu- 
sion, it is well to bandage with cotton, and to secure immobility by 
means of a plaster of Paris bandage, after the swelling shall have 
subsided. 



CHAPTER LXVII. 
SHOCK— COLLAPSE. 



Shock is the depression that is caused by severe injuries, surgi- 
cal operations, or great mental disturbance. It is the result of a 
profound impression made on the cerebro-spinal axis, either 
directly through some afferent nerve, or through the circulation. 
It may be reflex and slight, like the temporary faintness which 
soon passes away, or so severe as to induce a vital depression 
that is almost instantaneously fatal. It has already been shown 
that it is not the bullet in the heart that kills, but the impression 
upon the whole nervous system which is its consequence. In such 
an instance the shock is the direct result of the impact. But no 
less fatal may be the indirect effects of a mental impression. It 
is related that the janitor of a medical school had made himself so 
obnoxious to the students that even his life had been threatened. 
As the result of a conspiracy among them he was captured one 
night, conveyed to a sepulchrally draped room, shown a block and 
ax, and informed that he was to be executed. Amid the solemn 
and impressive surroundings he was seized by the masked men, 
his neck bared and placed upon the block, when the executioner 
struck with a towel wet in ice-water. The victim was taken up 
dead. The shock was as complete as though the actual ax had 
been used. 



308 ORAL PATHOLOGY AND PRACTICE. 

There is a wide difference in the susceptibility of different 
persons to shock. Some are of an emotional nature, and compara- 
tively slight mental impressions of a depressing kind produce pro- 
found effects. Others are more stolid and apathetic, and lose their 
nervous equilibrium less readily. It is well known that an unim- 
portant mishap will, in some instances, produce fatal effects, while 
in others the system will successfully withstand the gravest 
injuries. The immunity of drunken men to the results of accident 
is proverbial. Their intoxication so exalts or stupefies the nervous 
system as to fortify it against or exempt it from shock, the usual 
result of injury. 

The shock that is caused by mere mental impression is more fre- 
quent and often more profound than that produced by actual vio- 
lence. Especially is this the case with nervously susceptible people. 
The mere sight of a dentist's instruments too ostentatiously 
paraded may induce a depression and shock to a nervous female 
that will be absolutely more injurious than the contemplated opera- 
tion. Any incivility of manner or unnecessary roughness of 
method on the part of the operator may, to a timid child, be worse 
than the real pain, because it can induce a more profound shock. 
Infants suffer less from shock than adults, other things being pro- 
portionally equal, as the element of apprehension, or mental im- 
pression, is eliminated. In the light of these truths it is easy to 
comprehend why the gentle, suave, sympathetic dentist is able to 
perform with comparative ease to the patient operations that another 
finds absolutely impracticable. 

It is because of the limiting of the primary shock that opera- 
tions under the influence of an anesthetic are possible and safe, that 
otherwise would be fatal. The beneficence of these agents and the 
glory of the discovery of anesthesia is not confined to the im- 
munity from pain which they give, but they have saved lives 
almost innumerable through their making feasible operations 
that before were impracticable. 

The usefulness of prophylactic remedies, to be employed before 
dental or oral operations, lies in their ability to prevent shock to 
the nervous system, either by stimulating it so that it can success- 
fully withstand disagreeable impressions, or so stupefying it as to 
make it insensible to them. In either case the primary shock is 
correspondingly lessened or inhibited. The entire confidence of a 



SHOCK COLLAPSE. 309 

patient once secured, especially that of a child, the nervous system 
will without injury undergo, or even be insensible to, pain that 
under other circumstances would be unbearable, because the 
deadly influence of shock is avoided. It may readily be conceived, 
then, that the subject is of paramount importance to the operative, 
dentist, and that it is his bounden duty to study it with care. In 
this connection, the remarks upon nervous influence in the chapter 
on Hypersensitive Dentine will be found useful. 

The distinction between shock and collapse is one not easily 
made plain, nor is it necessary here to draw a fine discriminating 
line. It is sufficient if we consider shock as the result of either 
mental or physical violence, while collapse is the final conse- 
quence of continued exhaustion. Thus the impact of a bullet may 
induce shock, but the slow bleeding that may succeed it will 
finally end in collapse. 

Shock may not only be the result of different kinds of injury, 
physical or mental, but it may assume different forms. It is im- 
possible to draw a clear line of demarkation that shall place in 
separate categories all those which are possible, but for con- 
venience they may be classed as torpid, excitable, and delayed. 

In torpid, or apathetic, shock the symptoms may be almost 
entirely referred to vaso-motor paralysis. The circulation is mate- 
rially modified. There will be a pallor of the skin and of the 
mucous membrane, with coldness, especially of the extremities, 
and the patient may be covered with a cold perspiration. The 
expression of the face is changed or lost, the pupil of the eye is 
dilated and does not respond readily to light. There is irregular- 
ity of the action of the heart, with a weak, thready, and perhaps 
almost imperceptible pulse. The respiration becomes slower and 
more superficial. There may be partial or complete insensibility, 
mental inactivity, and loss of control of the voluntary muscles. 
There will be depressed bodily temperature, perhaps to be followed 
by a corresponding rise, and in some instances nausea, and possibly 
vomiting. 

In excitable, or erethistic, shock the patient is restless, irrita- 
ble, easily disturbed, perhaps uncontrollable. There is found a 
disordered pulse, with irregular breathing and dilated pupils. 
Notwithstanding the actually depressed condition, there will 
be the appearance of unnatural activity. The sufferer may per- 



310 ORAL PATHOLOGY AND PRACTICE. 

haps exhibit an impatience with and opposition to the institu- 
tion of the proper remedial measures, or the continuance of any 
necessary operation. To the operative dentist, these symptoms 
are often premonitory of a more profound impression, and are not 
to be disregarded. Upon their appearance he should use 
redoubled care to avoid further nervous injury, and should 
promptly administer an anodyne. 

Delayed shock is the condition in which the symptoms are only 
manifested some hours after the injury or nervous impression has 
been received. They do not materially differ in reality, and may 
be of either the torpid or the excitable character. They may be 
the result of a slow and concealed hemorrhage. This type is often 
observed after dental operations that were not of a serious nature, 
but which were considerably prolonged. The patient probably has 
not incurred any material harm, aside from the bodily depression 
that ensues, and the character of the symptoms will be rather of the 
excitable than the apathetic kind. 

The physical condition will not be materially different, no 
matter what the cause of the shock or the nature of the early 
symptoms. If it is serious the torpid state will gradually deepen 
into coma, and the excitement will as progressively subside 
into entire insensibility. The bodily heat may steadily become 
less, the breathing more superficial, the pulse weaker and more 
rapid, until death closes the scene. Sometimes this will be an 
unexpected end, the injury or nervous impression seeming totally 
inadequate to produce it. As has already been affirmed, the result 
often depends more upon the physical condition of the patient, and 
the bodily ability to resist or sustain the deadly depressing 
influence, than upon the nature or extent of the injury itself. 



CHAPTER LXVIII. 
TREATMENT OF SHOCK. 

The treatment of shock consists in the institution of measures 
to bring about a reaction. But these must be cautiously approached 
if the depression is very profound, or if it arises from or is accom- 
panied by any great loss of blood. There is danger that the 



TREATMENT OF SHOCK- 311 

reaction may be too great and exhaustive, or that recovery from 
the syncope or coma may be followed by a fatal return of the 
hemorrhage. Hence, in case of accident the precise condition 
should be determined before any extreme measures are attempted. 

Sometimes great difficulties are encountered in using the usual 
remedies. This is especially true in that common form of nervous 
shock called syncope, or fainting. Consciousness being lost, 
perhaps the patient cannot be made to swallow, and if fluids 
are forced into the mouth they will not be taken down the 
esophagus, but may go into the trachea and cause suffocation. If 
the shock is so profound that the circulation is arrested, there will 
be little use in attempting hypodermic medication; and if the 
breathing is suspended, inhalations of volatile stimulants will be 
impossible. There will, of course, be cerebral anemia, and this 
should be at once combated by laying the patient in a recumbent 
position, with the head as low as the rest of the body, or even 
lower. All obstruction to a free circulation, like clothing that is 
too tight or a violently flexed position of any limb, should be 
remedied. The lower extremities may be raised, and pressure 
used to press the blood out of them toward the head. If there is 
blueness of the lips, it may indicate that the head is too low, or 
that there is some obstruction about the neck. 

As soon as possible, warm stimulating drinks should be given, 
such as dilute whiskey or brandy. Volatile stimulants may be 
applied to the nostrils, such as ammonia, nitrite of amyl, etc., but 
care should be observed to avoid their being so unduly strong, or 
so persistently applied, as to cause suffocation. If the body is 
cold, external heat should be applied by wrapping the patient in 
hot blankets, or by laying bottles filled with water, not too hot, in 
the axillae and about the body. Chafing the extremities should not 
be resorted to until consciousness has returned, lest it draw away 
the blood from the head, where it is most wanted. 

Artificial respiration should be used if the breathing is sus- 
pended and is not readily resumed. This may be continued as long 
as is necessary, but it should not be violent. Every precaution 
should be taken to avoid the deepening of the shock. It is need- 
less to say that in the unconsciousness resulting from drowning, 
the violent rolling of the body upon a barrel or other object is the 
surest way to extinguish whatever of vitality may remain. 



312 ORAL PATHOLOGY AND PRACTICE. 

If the stomach will not retain remedies, or if the patient can- 
not swallow, stimulating drinks may be administered as enemas, 
and alcoholic dilutions, or strong coffee, with carbonate of am- 
monia, etc., will be almost as useful as when given by the mouth. 

Hypodermic medication is very useful when the circulation has 
been maintained or restored. The activity of the heart may be 
stimulated by strychnine and digitalis. The respiration may be 
strengthened by atropine. These remedies should be given in 
large doses. Park recommends that in serious emergencies there 
may be given in one hypodermic injection one c.c. of tincture of 
digitalis, with one-twentieth of a grain of strychnine and one- 
hundredth of a grain of nitro-glycerine. This to be repeated as 
often as necessary, or digitalis alone may be administered at fre- 
quent intervals. 

In case the shock takes the form of extreme nervous excitement, 
anodynes should be given. Opium, in the form of morphine sul- 
phate, is the most effective, and one-eighth to one-quarter of a 
grain may be administered hypodermically. The patient should 
be kept as quiet as possible until reaction is complete. 

When the shock is due to great loss of blood, as from tooth 
extraction, a saline solution, consisting of sterilized water iooo 
parts, ammonium carbonate i part, and common salt 6 parts, may 
be slowly injected, the nearer to the place of injury the better. 

The hypodermic syringe should always be kept in order, and 
be thoroughly sterilized before being used. The proper remedies 
may be obtained in tablet form, ready prepared for making 
solutions. The operator, before using the hypodermic solution, 
should see that no air is in the barrel, whence it may be driven 
into the circulation. This may be determined by holding the 
point of the syringe up after filling, and expelling the air by 
means of the piston. 

Of course, every operation is inhibited during the existence of 
shock. It matters not what form it may take, whether that of 
increasing lethargy or growing excitement, the attention 
must at once be given to securing- recovery. If indications 
of hysteria are observable, that may be one of the symptoms 
of excitable shock, and the patient should be given an anodyne 
and placed in a recumbent position in a quiet place, the operation, 
if it be dental, not to be resumed until another day. 



TREATMENT OF SHOCK. 313 

No one suffering from any form of shock, the result of an oral 
operation, should be allowed for a moment to remain in the operat- 
ing chair, as the recumbent position is the first essential. This 
does not seem to be properly appreciated by dentists. The extrac- 
tion of teeth, especially when an anesthetic is administered, can be 
much better accomplished when the patient is lying down. A 
couch, specially adapted to the purpose, should be provided by 
those who give anesthetics for the extraction of teeth. The danger 
from administration is very materially lessened, while convenience 
in operating is proportionately increased. The couch should be 
about the height of a common table, and only wide enough easily 
to hold the patient. Standing on either side for upper teeth, and 
at the head in extracting lower ones, the operator has much 
better command of the situation and is less liable to fracture tooth 
or alveolus, while the chances of dropping a fragment into the 
trachea, or of choking the patient with blood, are very materially 
lessened. Recovery from anesthesia, and from the shock conse- 
quent upon the operation, are much more prompt and satisfactory. 
No general surgeon would for a moment even consider the ques- 
tion of operating in any case with the patient sitting up. Dentists 
should change their methods, and — at least in operations involving 
the administration of anesthetics and the extraction of a number 
of teeth — adopt a position that is surgically more appropriate. 



INDEX. 



Abrasions and erosions of teeth, 233. 
Abscess, blind, 121. 
chronic, 125. 
discharging, 122. 
incipient, 121. 
vs. ulcer, 117. 
Acid reaction in tooth erosion, 235. 
All growth by alternate periods, 74. 
Aluminum splint, 301. 

Alveolar abscess, abortive treatment of, 130. 
definition of, 117. 
suppuration of, when to be prompted, 

131. 
symptoms of formation of, 129. 
treatment by absorption of remedies, 

133- 
treatment from outside, 133. 
Anemia and plethora, 28. 
Aneurisms, 288. 
Anesthesia vs. analgesia, 155. 
Animals can assimilate nothing except the 

organic, 7. 
Ankylosis of teeth in sockets not at all 

probable, 245. 
Antacids in chemical erosions, 237. 
Antiseptic formulae for caries, 101. 

precautions, importance of, 24. 
Antiseptics, list of, 21. 

usually germicides, 19. 
Antral disease, early symptoms of, 166. 

treatment of, 167. 
Antrum a resonant chamber, 161. 
drainage tubes in, 169. 
diseases of, principally catarrhal, 163. 
foreign substances in, 164. 
septa dividing, 171. 
varies in size and shape, 161 
Articulations, classification of, 303. 
Asepsis, essential in plantation, 239. 
Auscultation and percussion, 269. 

Bacteria, self-limiting, 14. 

Benign and malignant tumors, comparative 
symptomatology of, 188. 

Bleaching discolored teeth, 226. 

Bloodvessels of pulp without usual muscu- 
lar coats, 104. 

"Brow ague" of malarial origin, 153. 



Cachectic conditions, 36. 
Cancers, malignant growths, 185. 
Carcinoma, 186. 

Caries of implanted teeth not unlike ordi- 
nary dental caries, 243. 

of alveolar process, 194. 
differs from bone caries, 194. 
treatment of, 197. 
Causes of sensitive tooth tissue, 105. 
Cauterization of fistulous tract, 132. 

of wounds, 290. 
Cementum a modification of bone, 96. 
Chancre the primary syphilitic sore, 251. 
Chancres in the oral cavity, 265. 
Chancroid not constitutional, 261. 
Chancroids, multiple, auto-inoculable, pro- 
duce no oral lesions, 262. 
Cholera bacillus, 20. 
Classification of tumors, 183. 
Coagulation of dentinal fibrillae, 213. 
Cocain poisoning, 278. 
Condylomata of syphilis, 260. 
Contamination by bacteria, 23. 
Cyst, definition of, 175. 
Cysts, classification of, 177. 

treatment of, 181. 

where developed, 176. 

Death merely cessation of function, 5. 
Death-rate percentages, 72, 78, 79. 
Defects in enamel, acquired or secondary, 
233- 

congenital, 227. 

when congenital cannot be pathological, 
228. 
Delayed or non-union in fractures, 297. 
Dental caries, early theories concerning, 90. 

in animals, 87. 

medicinal treatment of, 99. 

Miller's demonstration, 91. 
theory, 92. 

not of modern origin, 87. 

result of infection, 93. 
Dental pulp not normally sensitive, 102. 

without lymphatics, 106. 
Dentigerous cysts, 180. 
Dentine a modification of bone, 96. 
not normally sensitive, 102. 



3'5 



3i6 



INDEX. 



Dentition, appearance of gums in disturbed, 
82. 
disturbances of, due to reflex nervous 

action, 70. 
general considerations, 67. 
natural appearance of gums in, 82. 
not the principal cause of high death- 
rate among children, 71. 
period of, a transitional one, 68. 
real disturbances in, 84. 
due to reflex nervous action, 85. 
lancing of gums in, 86. 
Denudation a cause of sensitive dentine, 

208. 
Denudation caries of alveoli, 195. 
Digestive disorders not due to teething, 74. 
Diphtheria, bacillus of," 23. 
Discoloration not usual in living teeth be- 
yond superficial deposits, 225. 
Discolored teeth, causes of, 226. 

general considerations, 225. 
Dislocation, definition of, 303. 
Dislocations, classification of, 304. 

reduction of, 305. 
Drainage in necrosis, 203. 
Drainage tube in wounds, 289. 
Dressing of wounds, 289. 



Edentulous jaws, 232. 
Enamel, its character, 98. 

only hard structure not protected from 
exposure, 97. 
Epithelioma, 186. 
Epulitic tumors, 189. 
Erosions and abrasions of teeth, 233. 

may be the result of acid secretions, 236. 

not the effect of wear, 235. 
Eruptive diseases as a cause of imperfect 

enamel, 230. 
External treatment of alveolar abscess, 

133- 
Extraction and replantation, 238. 

in necrosis may be injudicious, 201. 

recumbent position in, 313. 

Facial neuralgia, definition of, 150. 

paralysis, definition of, 154. 
Faradic current in paralysis, 157. 
Fermentation, alcoholic and acetous, 13. 

definition of, 9. 

essentials for, 10. 
F'erments, organized and unorganized, 9. 

segmentation, gemmation, and fission, 10. 

spore formation in, 11. 
Fibrous ankylosis, "false joint," 298. 
First intention, healing by, 40. 



Foraminal opening not always a simple 

operation, 113. 
Formation of dentine, 207. 
Frontal sinus, its degenerations, 173. 

opening of, 174. 
Inunction, definition of, 1. 

in the new-born infant, 75. 
Fungi, aerobic and anaerobic 13. 

classification of, 5. 

obligate and facultative, 13. 

pathogenic, saprogenic, and pyogenic, 14. 

their office, 4. 
"Fur" coating of the tongue, 279. 

Gangrene, 44. 

Garretson's experiments with acids in caries 

and necrosis, 196. 
Gentle hands and sharp instruments in ex- 
cavating sensitive dentine, 215. 
Germicides, disinfectants and deodorants, 

19. 
Glossitis, 65. 

in syphilis, 266. 
Granulation of food in infants, 76. 

or second intention, 41. 
"Green stain," 136. 
Gum appearances in diagnosis, 280. 
Gums or gingivae inflamed, 50. 

inflammation of, due to lack of care, 52. 

tissues of, 50. 

Healing "from the bottom," 285. 

of wounds, 285. 
Hemorrhage, arterial, venous, or capillary, 
291. 
excessive, 290. 
from wounds, 287. 
Hemorrhagic diathesis, 292. 
Hereditary or congenital syphilis, 262. 
Homologous and heterologous tumors, 183. 
Hutchinsonian teeth, 262. 

not always pathognomonic, 264. 
Hypercementosis presents no special symp- 
toms, 222. 
sometimes accompanied by osteophytes, 

222. 
the analogue of hyperostosis, 222. 
Hyperemia and ischemia, 29. 
Flypersensitive dentine, general considera- 
tions, 205. 

Impacted teeth a cause of necrosis, 199. 
Implantation an accepted method of prac- 
tice, 241. 
Induration of exudate, 39. 
Indurations, 135. 
Infection, how carried, 23. 



INDEX. 



317 



Inflammation a destructive process, 27. 
definition of, 28. 
early stage a hyperemia, 27. 
only one distinct form of, 26. 
predisposing and exciting causes, 31. 
result of irritation, 28. 
symptoms of, 34. 
termination of, 46. 
by resolution, 48. 
by suppuration, 49. 
Infundibulum may discharge in antrum, 

165. 
Injudicious feeding of infants, 76, 80. 
Insalivation, 1. 
Interdental splint, 301. 
Involucrum in necrosis, 201. 
Irritation makes pulp and dentine sensitive, 
104. 

Kowarski's paste for retaining loose teeth 
in position, 241. 



Lancing of the gums, 86. 
Leucocytes, ameboid forms, 17. 

changes in, 37. 

MetchnikofF s theory, 17. 

number increased in inflammation, 38. 
Leucoplakia of syphilis, 261. 
Ligatures for holding teeth in position, 241. 
Living portions of bone subject to inflam- 
matory conditions, 191. 
Localized gingivitis, 144. 
Luxation of inferior maxilla, 305. 

Malnutrition, 3. 
Massage in paralysis, 157. 
Matter, general classification of, 4. 
"Mechanical abrasion," 234. 
Membrane lining antrum, 162. 
Mental shock most profound, 308. 
Mercury a specific in syphilis, 254. 
Method of attachment of implanted teeth, 

243- 
Mucous plaques or patches, 257. 
Mummified pulps, 120. 

Necrosis, 45. 

Necrosis, an analogue of gangrene, 198. 

an indication of debility, 198. 

causes of, 199. 

diagnostic signs of, 201. 

treatment, local, operative, and general, 
202. 
Neuralgia, treatment of, 153. 
Neuralgias, symptoms of, 151. 



New pericemental formation in case of im- 
plantation, 244. 

No line of demarkation between normal 
and hypertrophied cementum, 224. 

Noma, or cancrum oris, 56, 59. 

Normal dentine insensitive, 206. 

Nourishment of bone, 190. 

Nutrition changes in tooth tissues, 159. 

Obtunding sensitive dentine, 211. 

Odontoblasts found within the pulp, 216. 

Odontomata, classification of, 179. 

Opening the antrum, 168. 

Operations inhibited during shock, 312. 

Operative measures in necrosis, 204. 

Oral syphilitic lesions dangerous, 249. 

Organization of tissue, 42. 

Osteitis, or inflammation of bone, 191. 

always a result of periosteal inflamma- 
tions, 200. 

treatment of, 193. 

Papain as a pulp digester, 222. 

Paralysis may be loss of tactile sense or 

insensibility to pain, 155. 

of fifth and seventh nerves, 155. 
Pathology, definition of, 2. 

oral, 2. 
Percussion in articulation, 269. 
Pericemental abscess, 118. 
Pericementitis, comparative symptomatol- 
ogy of, 115. 

its character, 111. 
Pericementum, a vascular organ, in. 

separated in alveolar abscess, 127. 
Phanerogams and cryptogams, 7. 
Pharyngitis in cleft palate, 62. 
Pharynx, definition of, 61. 
Physical diagnosis, importance of, 268. 
Physiology, definition of, 2. 
Plantation of teeth, 238. 
Plastic exudate, 39. 
Pockets in the alveolus, 146. 
Pregnancy, dental caries in. 159. 
Prophylactics in dental operations, 214. 
Proud flesh, 285. 
Pulp chamber, opening of, 120. 

capping, when interdicted, 106, no. 

derives its blood supply from the peri- 
cementum, in. 

digestion, 222. 

disinfection, 131. 

infection, methods of, 121. 

stones in substance of pulp, 217. 

without usual absorbents, 106. 
Pulpitis, comparative symptomatology of, 
"5- 



3'8 



INDEX. 



Pulpitis, general character of, 102. 
successive stages in, no. 
treatment of, 108. 
Pulse and condition of arteries, 273. 
definition of, 269. 
different kinds of, 271. 
differs with individuals and conditions, 

269. 
method of taking, 270. 
rate at different ages, 270. 
readings depend on force of heart, 273. 
sphygmographic tracings, 271. 
where best taken, 270. 
Pus, composition of, 22, 43. 
different kinds of, 44. 
may be discharged at a distance from seat 

of abscess, 127. 
must be evacuated, 49, 124. 
Pustular eruptions of syphilis modified in 

the mouth, 258. 
Pyorrhea alveolaris, definition of, 141. 
in domesticated animals, 142. 
etiology of, not positively determined, 

142. 
of three distinct kinds, 144. 
uric acid diathesis in, 143. 



Ranula, a retention cyst, 178. 
Reduction of fractures, 293. 
Removal of enamel deposits, 147. 
Resection of inferior dental artery not 
necessarily fatal to vitality of pulp, 
114. 
Resistive power of function, 16. 

experiments in, 17. 
Resolution, a building up and tearing 

down, 40. 
Resorption and osteoclasts in cases of plan- 
tation of teeth, 246. 
Respiration, definition of, 273. 
either abdominal or thoracic, 274. 
in diseased conditions, 275. 
in normal conditions, 274. 
Respiratory murmurs, 275. 
classification of, 275, 276. 
rales, 276. 
Revivification of dead tissue impossible in 

plantations, 243. 
Root filling need not go beyond foraminal 

delta, 134. 
Root filling, when permitted, 132. 
Roots of teeth penetrating antrum, 163. 



Salivary calculus, formation of, 137. 
Sarcoma, 185. 



Secondary dental formations in animals, 
218. 
pockets in alveolar abscess, 127. 
pulp formations, true dentine, 216. 
Selective action of acids in caries, 196. 
Sensitive dentine, its causes, 207. 

point near apex of root, 134. 
Septic condition, 18. 

indications of, 129. 
Sequestrum in necrosis, 201. 
Serumal calculus, 138. 

distinctly irritating, 139. 
formation of, 139. 
Shock, definition of, 307. 
different forms of, 309. 
the result of direct or reflex nervous 

action, 30. 
treatment of, 310. 
"Smoker's patches," 266. 

So-called diseases of dentition confined to 
a few months of the year, 77. 
treatment of, 81, 83. 
Sprain, definition of, 306. 
Stomatitis, aphthous, 55. 
follicular, 54. 
treatment of, 56. 
ulcerative, 55. 
Suppviration, 22, 43. 

when to be encouraged, 131. 
Susceptibility to shock, 307. 
Sympathetic disturbances, general consid- 
erations, 158. 
Syphilides or syphilodermata, 255. 
macular, papular, and pustular, 256. 
of the mouth, 257. 
Syphilis, appearance of chancre in, 253. 
care in diagnosing, 251. 
chancre rarely suppurates, 254. 

usually single, 254. 
definition of, 250. 
general considerations, 246. 
lymphatic glands affected in, 254, 258. 
mercurv a specific in, 254. 
not auto-inoculable, 254. 
only to be diagnosed by clinical history 

and grouping symptoms, 268. 
period of incubation of secondary, 255. 
of incubation of tertiary, 259. 
of incubation of primary, 252. 
readily yields to treatment, 251. 
secondary stage, 255. 

period of incubation, 255. 
tertiary form of, 259. 

period of incubation, 259. 
the chancre single, 254. 
Syphilitic discharge sometimes non-infect- 
ive, 249. 



INDEX, 



319 



Syphilitic gumma and tubercle, 260. 
virus intensely infective, 248. 

Teeth are living organs, 94. 

chemical composition of, 95. 

congenitally without enamel, 229. 

modifications 01 bone, 94. 

with congenitally imperfect enamel, 230. 
Tents and plugs in antrum, 170. 
Test for success of an operation, 208. 
Third intention, healing by, 43. 

variety of pyorrhea, 149. 
Thrush in children, 56. 

Tongue, appearance of, in health and dis- 
ease, 64. 

in health, 279. 

injuries of, from the teeth, 66. 
Tonsillitis, 63. 

Tooth tissues of organic origin, 98. 
Treatment of alveolar caries, 197. 

of wounds, 285. 
Tumors or neoplasms, 182. 



Ulcer distinguished from abscess, 117. 

Vaso-motor nerves, 32. 

Vegetable alone can organize the inor- 
ganic, 6. 
Vitiated secretions in sensitive dentine, 209. 
Von Recklinghausen's theory, 39. 

Wandering cells of Von Recklinghausen, 

39- 
White deposit, 135. 
Wounds, classification of, 283. 

definition of, 282. 

succeeded by shock, 282. 

Yeast fungus, 12. 



Zone of infected dentine, 92. 
Zymotic diseases, 15. 



OCT 



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LIBRARY OF CONGRESS 



QD02b0flb455 







